Episode 100: Senior Care and Trump's Budget with Nathan Boucher

Disclaimer: Unedited AI Transcript

Larry (00:07):

You are listening to specifically for Seniors, a podcast designed for a vibrant and diverse senior community. I'm your host, Dr. Larry Barsh. Join me in a lineup of experts as we discuss a wide variety of topics that will empower, inform, entertain, and inspire as we celebrate the richness and wisdom of this incredible stage of life.

Larry (00:40):

A fact check at the White House website, proclaims quote, president Trump will always protect social security and Medicare. Close quote, it goes on to quote Elon Musk saying, the waste and fraud in entitlement spending, which is most of the federal spending, is entitlements. So that's like the big one to eliminate. That's the sort of half trillion, maybe six to 700 billion a year after a list of facts about fraud, improper payments to deceased individuals, and improper payments to both social security, Medicare, and Medicaid services. The page goes on to ask, quote, what kind of a person doesn't support eliminating waste, fraud, and abuse in government spending that ultimately costs taxpayers more? I'll include a link to this page in the show notes below.

Larry (01:52):

Am I missing something? First? Social Security and Medicare are not entitlements. They are services for which older Americans have paid for by deductions from their salaries. And second, where is in this so-called fact sheet plans for how President Trump is going to preserve Social security and Medicare, except for a statement that reads, the Trump administration will not cut Social Security, Medicare, or Medicaid benefits. President Trump himself has said it over and over and over again. Conversely, president Trump's budget seeks to reduce or eliminate the older Americans Act to dissolve the administration for community living and cut funding to critical services that help older adults to live independently in order to be able to understand more completely what's going on. We called on Nathan Boucher to explain the effect of Trump's real budget proposals on senior care. Nathan is associate research professor in the Sanford School of Public Policy and Duke University's faculty at Sanford School of Public Policy, the medical School and the Nursing School. He is also a senior fellow at Duke Center for Study of Aging and Human Development, as well as Duke Margolis Center for Health Policy Core Faculty. Welcome to specifically VAs Nathan.

Nathan Boucher (03:47):

Thank you. Thank you, Larry. Appreciate you inviting me.

Larry (03:54):

Let's start off by defining the purpose of the Older Americans Act and the administration for community living.

Nathan Boucher (04:03):

Sure, sure. So I, just to kind of keep it succinctly, 'cause these are are big complex organizations, but the Older Americans Act came about in 1965 right around the same time as Medicare and Medicaid as it turns out. And that is a bevy of services that it provides for, it's, it's looking at transportation for seniors programs like Meals on Wheels, legal assistance, elder abuse prevention health promotion efforts when it comes to specifically and, and most importantly, I think low income, possibly isolated, often at risk older adults who really depend on community-based services to maintain independence in their communities. And then the administration for community living that came about much later, about 2012 under the Department of Health and Human Services. And that oversees the Older Americans Act programs. And their mission is to maximize, again, independence, wellbeing, the health of older adults and people living with disabilities as well as their families and their caregivers that support them in the community.

Nathan Boucher (05:15):

That caregiving piece is so vital, so supporting them is really important. So these were all very consolidated federal efforts up until recently, largely under, you know, one or two roofs if you will, to try to keep it organized to keep that whole communication and referral process organized. And there's now demonstration by the current administration that they want to really parse it out and, and stick at it and, and to different places. And I really think that can be a detriment and will only serve to hobble the, the great services that we have available to older adults in America.

Larry (05:55):

Are they in under one of the cabinet's departments?

Nathan Boucher (06:00):

Yes. A Department of Health and Human Services. But it's being proposed that they want to divvy up the OAA or the Older Americans Act pieces to different departments. And I think by doing that, what, what two things would happen? I I, I think it would denigrate what's available, and it would, like I said, further hobble communication and referral processes.

Larry (06:25):

So it'll have a direct effect on the critical services for older adults.

Nathan Boucher (06:31):

That that is what, what I and, and many other experts in this field believe. Yes.

Larry (06:37):

Isn't that an assault on older Americans directly?

Nathan Boucher (06:42):

I, I think so. Everybody worked very hard in their lives and now are older and, and, and hope to get those services from Medicare and Medicaid and the Older Americans Act. And, and I do believe that this is an, an assault on those services and, and supports, understand it's not just money flow, it's, it's supportive services. It is communication, it is health promotion, and it is also additional supports for, for the families that do all that work out in the community for older adults living at home. We're trying to keep people out of facilities, right? Facility care is very it can be helpful when needed, but, but it is not the place to be if you don't truly need it. It's very high costs. So if folks can, can remain at home and their families can be supported to support them, that's, that's a really key part of the bebe of services that the OAA and the ACL provides.

Larry (07:42):

The older adult services are particularly interested interesting for the listeners to this podcast, but it affects younger adults with disabilities as well.

Nathan Boucher (07:56):

Absolutely. And, and understand that our conversation here about, about the denigration of the Older Americans Act and the ACL is happening in tandem with the proposal that Medicaid should be cut that is being proposed right now and is receiving initial support and, and votes at the house level. And we need to see what happens. But these go hand in hand. Medicaid funding is part and parcel to the support for older adults and people living with disabilities out in our communities in America today. It is a myth that Medicare provides services for, for older adults. Long-Term care, specifically, it is Medicaid. It's either cash money from people's pocketbooks or it is Medicaid that largely provides our long-term services and supports and home and community-based services. So we are looking at, at both a denigration of these offices for the Older Americans Act and the ACL, but also an overlay of major funding cuts for Medicaid that actually back up all of the components in the Older Americans Act.

Larry (09:05):

And it's not just for services, it's elimination of some of the research that goes along with it.

Nathan Boucher (09:13):

Absolutely. there, there is now the, there's a lot of research through NIH and, and the Veterans Administration and, and other conduits. But there is hand in hand research that, that goes with the funding for the Older Americans Act. And, and that is true. If, if it, it's not, what the administration is doing is, is not just degrading services and research, but also the drive to want to make programs better, right. The, the, the pro, pro learning, pro research to try to improve services and improve quality for older Americans in our nation. And so, so it's not just the, the practical dismantling, but also an ethos that is now invading America today.

Larry (10:07):

Yeah. And that seems to be going along with all research, medical research in general.

Nathan Boucher (10:15):

It is true. Yeah, I, I don't want to talk too much about my own, my own jobs per se, but you know, there are certain areas that, that the research is still being supported. But there are other areas where research is at risk for sure, and all institutions are bracing themselves for potential major changes in research funding.

Larry (10:37):

So what in the administration's stance makes this, this cutting of funds necessary?

Nathan Boucher (10:49):

I, I think there's calls for efficiency, which every new administration does. They may not give it a, a funny name <laugh> for, for their effort, but, but every administration does that as you go back and, and look, historically, this is not a new idea. Waste fraud and abuse exists at, at every level of private and government organizations. They have yet to truly find waste, fraud and abuse. It, it, it seems. But sure. I'm, I am all for, let's keep, keep things efficient. Let's avoid duplication. Let's use taxpayer dollars wisely. I, I am all on board with that. But, but this is a an assault, as you say a very drastic chain of events that is not taking into consideration the things that really do work well in the US government for older adults.

Larry (11:47):

So President Trump has claimed that Social Security, Medicare, Medicaid, will not be touched, and he has at those, the website has said, repeated this over and over and over again, but in light of the proposals in the I hate to even say it, big, beautiful bill. Is there any re reassurance that senior citizens will continue to get care?

Nathan Boucher (12:27):

I think services will continue on some level, but if you cut Medicaid dollars, they will be greatly curtailed. Understand that we have 50 different state legislators and governors all need needing to balance their budget. They can't just raise their deficit like the, the federal administration and legislation can. So each state relies on these Medicaid dollars. And if that is not flowing into states whether, whether you are your red green, purple <laugh> or, or blue of a state there, you're not going to be able to get those Medicaid dollars. And somebody will have to pay people will either stave off care till they get sicker, and then they still show up at the er, and then health systems and taxpayers still have to foot the bill. So if you're getting rid of the mechanism for payment to have people enrolled and well covered in Medicaid then, you know, we, we still have to pay for that care. And people are gonna get sicker and, and, and wait till they're, they're much sicker and, and and have to spend a lot more healthcare dollars once they do arrive at the emergency department.

Larry (13:46):

So there are two major proposals of the changes in Medicaid that have recently proposed, and these are being imposed on people who are already potentially very sick. There's a worth a work requirement and a community service requirement.

Nathan Boucher (14:18):

Mm-Hmm <affirmative>. Mm-Hmm <affirmative>. Now again, Medicaid is you know, means tested. But this additional work requirement being quite rigid with that, which will probably to, to some degree, each state will be able to interpret that as they have to date what those, what those requirements might be or, or how much recipients might, might get held to those requirements. It's not going to be possible for some people to meet those, those work requirements understand that it's in this economy or any economy, it's, you know, it's hard to to make ends meet for many individuals. Many have dependents, many have to work several jobs, and even then still don't have enough money to pay for health insurance. So, so Medicaid is so critical to individuals. And, and as you know, and your listeners know of course if you, if you are able to work, then you are potentially able to get employer-sponsored insurance, which is how most Americans, even after the Affordable Care Act, most Americans still get employer-sponsored insurance. But if you're unable to work because of physical or other mental illness and you're also, you know, caring for mom or dad as well as caring for, for younger children and sandwiched in, in that regard, if you will. Yeah, it's, it's very difficult to balance all these things. And and Medicaid, Medicaid really fills those gaps and is so critical to, to individuals, even the working poor.

Larry (15:55):

You mentioned that states can't have to stick within their budget and without the federal funding, are states gonna be able to provide even basic services for Medicaid?

Nathan Boucher (16:13):

I I can't imagine they'll be able to do it at the very same level. Understand there's already a state to state variation, right? Politics plays a, a key role and, and how much, how, how beneficial a state Medicaid program is. What menu of services are available to citizens in that state? It may vary. If you're in Massachusetts, it might be fairly fairly you know, provide quite a few things If you're in a state that may be is not as politically we'll say, liberal or as Democrat you sometimes find a trend that the state Medicaid program in, in a state like that is maybe not quite as, as as rich a series of, of services that are afforded. So, so I think there's, I don't see with the cuts and with dismantling of the Older Americans Act, I don't see there being a, a maintenance of what we have even now.

Nathan Boucher (17:12):

And there could be actually very harmful reductions in services that are allowed. What is basic service is open to a lot of interpretation. We don't do preventative care very well in the United States. We do trauma care very well. We do emergency care very well, but we don't, we don't do a lot of good preventative care and, and have our eye on the ball, you know, 10 years down the road for, for an individual as they age or maybe get sicker. So we don't do a lot of prior planning and preventing disease and Medicaid cuts and dismantling of the, the Older Americans Act. Will just further add to that those reductions.

Larry (17:56):

It would seem from what you just said, that this is going to adversely affect red states horror states more than it's going to bother the recipients of Medicare in wealthier to use

Nathan Boucher (18:15):

<Crosstalk> Medicaid. Yes. you know, just, just so that we're clear. Yeah. So for this is affecting re reductions in Medicaid. And so yes, I I it's hard to to to say that you know, off the cuff, but that has been the trend in the past is, is that you know, politically more conservative states tend to have not as robust Medicaid offerings. Each state does have a Medicaid program. But they can also choose in part what to do with those dollars that come from the federal government, which they then match at the state level. So they have a lot of latitude in doing that. But if they're getting less, less money, I think it's just plumbing, right? You know, if you're getting less flow <laugh> and support from, from the US government, then there's going to be less matching at the state level. And that will result in less services to give to current enrollees or even to add new enrollees at the state level.

Larry (19:16):

Where is this politically advantageous for the Republicans?

Nathan Boucher (19:21):

It's politically ad advantageous. And not to get too much into politics, 'cause that's not really my area. But I would, but I would say this results in useful talking points for people trying to get reelected among their, their various bases. However is just not good administration at the, the state level. It's not good budgeting at the state level. And you're still gonna have to pay for it. So, you know, if people seek care in your state and there's less Medicaid dollars or less people on Medicaid that, that care will still have to be paid for somehow. And that ends up coming out of, you know, potentially local taxes, potentially healthcare systems get inundated. Potentially local, smaller, especially rural hospitals may have to close because they're not they're not generating the revenue that they need to generate to maintain operations. And we, even under the, the current circumstances, we see rural hospitals closing here in North Carolina and and across rural areas of America. So if you think that's gonna get better <laugh> with Medicaid cuts it just won't, I don't see how it can,

Larry (20:35):

In addition to the work requirement, there's also a statement that people would have to verify their eligibility for Medicaid twice a year rather than just once. Aren't the Republicans just using paperwork to throw people off Medicaid?

Nathan Boucher (20:56):

On the face of it, that's what, you know, it sounds like to me. Again, I'm not a politician or, or, or, you know, delve too much into politics, but, but it just, on the face of it, the practicality is if there's more burden on the part of care recipients and Medicaid recipients that will serve to be, you know, a another hoop yet another hoop to jump through in order to maintain your Medicaid coverage or to initially get on Medicaid coverage. And, and those can pose as barriers. We all know as as family caregivers and aging Americans ourselves that you know, that n plus one task that we need to do that day can be enough of a barrier that it keeps us from, from doing stuff in sometimes in our own best interest because it's, it's, we're already overburdened with our own care or caring for others. And, and I, I think throwing up those extra barriers does not serve Americans health.

Larry (22:04):

How many people are these changes to health insurance, both Medicaid and the Affordable Care Act changes that are somehow thrown into this? How many people is this gonna affect?

Nathan Boucher (22:21):

I mean, I don't know the exact numbers, but it, it's millions. I, I think Medicaid is on the order of, you know, older adults and people with living disabilities could be, you know, more than 6 million individuals that this is going to affect directly. And I, yeah, I just and, and, and I think it's hard to even guess because there's, if Medicaid continued in its current state, there's, you know, potentially new enrollees that could be funded under that. So I think we're, we're looking at, at reductions in future enrollees and also reductions in, in services available to current enrollees. And I don't know the exact numbers on that, but we're talking many millions of individuals in the US

Larry (23:13):

And these changes were originally proposed to be enacted sometime in 2029, but they were pushed up till <laugh> surprisingly enough, right after the midterm elections,

Nathan Boucher (23:31):

Right? Yes. I mean I, I, I think I would do the same thing if we were playing politics, right? You, you'd want to make sure that, that you made the, these, these drastic moves that are gonna hurt a lot of people and possibly benefit some other people. You'd wanna time that correctly for, for yourself and, and for your own election runs.

Larry (23:55):

So what can we in the public do about this? How do we change it?

Nathan Boucher (24:05):

Well, I mean, I, I know sometimes people, you know, write your congress person <laugh>, people feel like that's a you know, not a good move. But I, but I think in, in the various localities, if, if Congress, people in their districts are hearing you know calls for change calls to not cut services and supports for older Americans and those living with disabilities, I think that does make a difference. And so that is part of, of advocacy and, and educating both our, our policy leaders lawmakers but also our local communities. I think mobilizing the various constituencies is important. We have the area agencies on aging, senior centers, other advocacy groups that can be engaged with letter writing campaigns town halls with, with policy makers and elected leaders testimonies at hearings. A key piece of this, as you already brought up, is, is trying our best to protect research collaborations across various social and, and healthcare systems.

Nathan Boucher (25:14):

You know, understand that major impacts on health outcomes also have social components, right? We talk about social determinants or influences on health. And that could be housing, transportation caregiving support. Those, when they're in place serve to keep older Americans and those living with disabilities at home independent as possible in their communities. I think again, and whatever we can do to inform the public and communicating that these risks of, of, of funding cuts to the general public and caregivers is going to affect us all, regardless of what sort of political stripes we might wear. This is, this is going to be a, a red and a blue state issue. This is going to be a rural issue for sure. And people in rural areas are, are across all political spectra. I, I just, I feel like this is going to affect us all. If the state cannot have the money to protect and, and pay for Medicaid services for their poor, everybody in that state is gonna feel it on some level.

Larry (26:27):

Do you have any, any anything to share that would make a lot of us who are older feel better feel more positive about what the future is gonna bring?

Nathan Boucher (26:45):

Well, there, there are two things going on here. I, I think the Medicaid, potential Medicaid cuts overtook our conversation a bit, because that is, you know, very much in the zeitgeist right now that that is a, a major issue on the table. But the, and we have to kind of wait and see on that and, and, and see if there are, are lawmakers who, regardless of their political background may say, Hey, our state really does need these Medicaid dollars. No, I'm not, I'm not for this. And we have to see what happens. However, it is a Republican controlled Congress, and and we have to see where that goes. The, the other issue is the older Americans Act and the administration for community living, those are administrative shuffles. It could be that that's temporary when a new president gets in the door.

Nathan Boucher (27:34):

They could maybe correct some of that situation and solidify once again what the services and supports that come under the Older Americans Act and the administration for community living, what that looks like under the, the next presidency. And then, you know, after, after these four years, I know that's cold comfort 'cause it's still four years of, of, of reshuffling potentially going on here for the Older Americans Act. But I, I think some of that could be temporary and corrected from an administrative point of view. The Medicaid cutting, cutting is a, is another story. Because those are, are, if it passes, those are changes that are due to come into effect past the current presidential administration years past the, the current presidential administration. So that, that, that would be more baked in for, for sure. But where, where there's a will, there's a way with policymakers and some of it that could even be corrected down the road.

Nathan Boucher (28:42):

I think we have so many awesome community-based services out there, senior centers, area agencies on aging. Some of that funding is, is, is not federal and state. Some of it's, you know, private foundation funding and charitable giving and, and so forth. And I, those, those people who work in those organizations are mission driven and will continue to do their best to provide what they can to older adults and people living with disabilities in our communities. So I think it's it's a hit to morale and not just funding, but you have so many dedicated folks that I work with on a daily basis here in North Carolina. So many dedicated people working in the, in the aging services community and the community serving those with disabilities. So I don't, I think that, that, that mission, that passion will continue. So I, I like, I like to think that that won't solve it, but, but it'll maintain a lot of what we have, I think.

Larry (29:48):

Do you think there are gonna be any staff cuts necessitated by these programs?

Nathan Boucher (29:55):

It, it, it may very well be. So because if there's not money flowing in, it's hard to maintain operations. Certainly at at county level and state funded offices, if they're receiving Medicaid dollars that then get cut nonprofit organizations some of that impact will trickle down to nonprofit organizations doing so much of that work in the community for older adults and people living with disabilities. So we'll have to see, we'll have to see what, what that ends up looking like. It's, it's a bit of a wait and see game. On, on the, the Medicaid cut question.

Larry (30:36):

Do you see any changes coming for the Affordable Care Act?

Nathan Boucher (30:42):

You know, the opponents of, of the Affordable Care Act for years have said, you know, get rid of it, but nobody ever has had a, a viable replacement option for that. And, and so now you've had hospitals and healthcare systems and business processes all baking in what the Affordable Care Act does for Americans and what it, what it serves to do. I think having a sweeping change, such as getting rid of the Affordable Care Act would be largely unpopular with health systems and, and and businesses. And so I, you know, Americans like the Affordable Care Act, it, it is actually pretty popular among, among Americans. And, and so I don't see that going away. Now there have been, over the years Supreme Court challenges that have sought to hobble the Affordable Care Act one of which was getting rid of the individual mandate or the requirement that you either had to have, be on insurance or receive a tax penalty at the end of, of the year, and they got rid of that individual mandate that helped bolster the, the pool of individuals that were being covered under the Affordable Care Act.

Nathan Boucher (32:07):

So right now we already, the individual, individual mandate hasn't been around now for several years. But the Affordable Care Act has continued. And yeah, I, I, I hope that remains in place. I don't see that going away. But again, that's, that's not the mean, the majority of Americans get their insurance through employer sponsored insurance and, and Medicare and Medicaid. So the Afford Affordable Care Act is important to, to many millions of Americans. But, but it's just a piece of the puzzle.

Larry (32:46):

It's been great talking with you. And now I see why a large proportion of your students gave you a favorable rating.

Nathan Boucher (32:57):

<Laugh>. Oh, you're looking at the ratings, huh? <Laugh>.

Larry (33:02):

Hey, I wanted to know who I was gonna be talking to

Nathan Boucher (33:05):

<Laugh>.

Larry (33:08):

But it's, it's an important discussion and I hope that we've given some hope to the people who are on, going to be on, might be on Medicaid with a great discussion. Thanks, Nathan.

Nathan Boucher (33:30):

Thank you, Larry. I really appreciate your time today.

Larry (33:33):

Thanks a lot.

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