Across the country, families are navigating how to take care of each other through age and disability. For many older people and disabled children and adults, support for activities like cooking and preparing meals, taking medicine, and getting dressed and bathing is essential. And most people prefer receiving care at home—77% people over 50 years old prefer to “age in place.” But the costs can be overwhelming: hiring a full-time home health aide, for example, typically costs close to $69,000 per year.  

For millions of people who need home- and community-based services (HCBS), Medicaid—the federal program that provides health care coverage to low-income people—is a lifeline. Through Medicaid, disabled people can get their health needs met so they can participate in their communities, and family caregivers can access support from professional care workers when they need it. Medicaid is particularly vital for women, who make up the majority of adult Medicaid beneficiaries and disproportionately take on family caregiving responsibilities. Women, especially women of color and immigrant women, also make up most of the direct care workforce—the paid professionals who provide HCBS, often relying on Medicaid for both their wages and their own health care coverage. 

However, due to the “One Big Beautiful Bill Act” (or OBBBA), which Republican leaders and President Trump enacted in 2025, more than 10 million people will lose access to Medicaid over the next ten years. This Big Ugly Bill made the largest cuts to Medicaid in the program’s history—roughly a trillion dollars over the next decade—to fund massive tax breaks for billionaires and large corporations. The law also provided historic funding for ICE and Customs and Border Patrol (CBP), boosting their efforts to terrorize and deport immigrants, who make up a large share of direct care providers. Unless policymakers act to reverse course, OBBBA will decimate our already underfunded long-term care system, which has left thousands of individuals and families without the support they need. 

Medicaid enables millions of disabled people and older adults to get the care they need to live, especially within their homes and communities.  

Medicaid is the main source of funding for home- and community-based services. Medicare, the federal health care program for seniors, only provides coverage for home health services in very limited circumstances, while most health insurance plans do not cover long-term HCBS at all.  

• In 2023, the overwhelming majority of people using Medicaid for long-term care (8.4 million) used it to receive care at home, while a much smaller share (1.5 million) used Medicaid to receive care at institutions like nursing homes. 

• But hundreds to thousands of people in some states remain on waiting lists for years before receiving HCBS, if they receive it at all. 

• In one survey, 83% of adults said it would be impossible or very difficult to pay $60,000 for one year of assistance from a home health aide.  

 Because of OBBBA and other attacks from the Trump administration, people will lose the home-based care they need.  

HCBS beneficiaries and their families are already bracing for OBBBA’s impacts, as the massive loss of federal Medicaid dollars is prompting state lawmakers to cut critical care services to make up for anticipated budget shortfalls. 

• Federal Medicaid rules require states to cover long-term care for people who need it when they receive this care in institutions (like nursing homes). But covering home-based care is considered “optional,” even though most people prefer this form of care. 
• Many states are facing budget pressures that are only intensified by OBBBA’s cuts to Medicaid, SNAP, and other programs.
  • While some states are looking to raise revenues to fill budget gaps, many others are planning to cut services—and so-called “optional” Medicaid services like HCBS are a prime target for cuts.
  • In fact, between 2010 and 2012, when states faced a drop in federal Medicaid funding, every state and D.C. made cuts to home care. 
• Across the country, policymakers have proposed drastic cuts to state HCBS programs that could force millions of people to seek care in institutional settings rather than in their homes and communities. For example:
  • In Idaho, Governor Brad Little approved legislation to cut $22 million from disability services. This may only be the beginning, given Governor Little’s budget proposal calling for $45 million in state Medicaid funding cuts—potentially through “removal of home and community based services” altogether, among other brutal cuts.  
  • Lawmakers in Colorado, Iowa, Nebraska, Missouri and Utah have already entertained massive cuts and changes to disability care in anticipation of budget shortfalls. While some of these efforts have not yet become law, the threat still looms. And Utah is also aiming to restrict HCBS through regulatory changes to who is eligible for these services. 

The Trump administration and congressional Republicans have also made baseless claims of “fraud” in HCBS programs to justify, for example, freezing more than $259 million in Medicaid dollars for Minnesota and threatening to withhold $2 billion annually. To preserve its federal funding, the state had to (at least temporarily) disenroll 3,411 health care providers due to administrative issues; fewer than two percent of these providers have been referred to the office of inspector general for follow-up. Cutting off funding does nothing to strengthen the integrity of the program—it just makes it even harder for families to get the support they need to live. 

In addition to making it harder to get care, Trump and Congressional Republicans’ cuts are making it harder to provide care, whether paid or unpaid. 

In the U.S., 63 million adults provide ongoing care to adults or children with a medical condition or disability. That’s almost one in four adults across the country—a far higher share than just a decade ago, as the need for care has grown along with our aging population. Family caregivers rely on Medicaid in multiple ways that are threatened by OBBBA’s cuts. 

• Most unpaid family caregivers are women, and many face economic insecurity that is compounded by rising out-of-pocket expenses associated with caregiving. More than 8 million family caregivers rely on Medicaid for their own health insurance (13% of 63 million caregivers), but many could lose coverage due to OBBBA’s new work reporting requirements and other hurdles, like changing the eligibility of legally-present immigrants and requiring states to conduct eligibility checks every six months—all designed to force people off the program.  

• In some circumstances, family caregivers can receive compensation through Medicaid HCBS programs for the care they provide for their loved ones. Or they can receive short-term help (respite care). But these benefits could disappear as states look to cut their budgets by scaling back HCBS. 

• More than one in three family caregivers rely on paid support, often from professional home health aides and personal care aides, to help care for their disabled or aging family member. 

Medicaid is also vital to millions of home care workers and other direct care workers who provide professional care services.

Because Medicaid is the primary funding source for HCBS, many direct care workers rely on Medicaid for their wages—and because those wages are so low, they often rely on it for health care coverage as well.  

These workers are now even more at risk because of OBBBA’s Medicaid cuts, as well as other anti-worker and anti-immigrant attacks launched by the current administration.  

• The Trump administration’s Department of Labor is working to eliminate federal minimum wage and overtime protections for home care workers, threatening to further suppress their already-low wages. 

• Close to one-third of home care workers are immigrants—and many are being routinely intimidated and even forced out of their jobs by the Trump administration’s cruel and unlawful immigration enforcement tactics, which are in large part funded by OBBBA’s massive budget increases for ICE and CBP.  

• Anti-immigrant policies traumatize both direct care workers and the families who rely on their support, tearing apart these relationships of trust and interdependence. Attacking immigrant workers will risk exacerbating the current shortage of direct care workers, make it even harder for people to get professional care. 

We deserve laws and policies that reflect what’s most important to every family—being able to take care of one another.   

Care is foundational to all of our lives—whether we receive care, provide care, or both. However, recent attacks from the Trump administration and congressional leadership are devastating an already-fragile system, leaving many families scrambling to access the care they need, and potentially forcing people to decide to forgo care because they cannot afford it. As Donald Trump and Republican leaders continue to prioritize the interests of the billionaire class over everyday people’s needs, the impact of the Trump administration’s cuts to care are just beginning. 

To stop further harm, state lawmakers should look to raise revenues from wealthy individuals and corporations to fill Medicaid funding gaps rather than cutting vital HCBS programs. And ultimately, our federal policymakers must reverse OBBBA’s Medicaid cuts and ensure that billionaires and corporations pay their fair share, so that everyone can care and be cared for.