When President Trump signed the budget reconciliation bill on July 4, few noticed the quiet death sentence it handed to millions of aging Americans who rely on home-based care. The law, once nicknamed the "One Big Beautiful Bill Act," doesn’t just let key Affordable Care Act subsidies expire—it actively dismantles the financial lifeline keeping older adults out of nursing homes and in the places they call home. According to Kaiser Family Foundation analysis, 4.2 million people—many of them seniors with chronic conditions—could lose health coverage by 2034. And behind that number? A collapse in home care services that families can’t afford to replace.
Medicaid Cuts Are the Real Crisis
The reconciliation bill doesn’t just end enhanced premium tax credits for Marketplace plans—it slashes Medicaid funding by billions, targeting the very programs that pay for home health aides, physical therapy in the kitchen, and medication reminders delivered by a visiting nurse. These services, known as home- and community-based services (HCBS), aren’t optional luxuries. They’re lifelines. For many, they’re the only reason they can avoid institutionalization.
History doesn’t lie. When federal funding tightened after the 2010 budget sequester, every single state cut HCBS. Forty states served fewer people. Forty-seven reduced payment rates to providers—some so low that aides quit, leaving seniors isolated. Now, with this new law, the same pattern is set to repeat, only faster. And it’s not just seniors. People with disabilities, veterans, and those recovering from strokes or surgeries are equally at risk. The Congressional Budget Office estimates these cuts will leave Medicare with 100,000 fewer beneficiaries by 2034, including lawful immigrants who’ve paid into the system for decades.
Food and Health Are Linked—And Now They’re Being Separated
Here’s the cruel twist: the same bill cuts SNAP by $186 billion over ten years. For older adults living on fixed incomes, that’s not just a lost meal—it’s a health emergency. Studies show malnutrition increases hospitalizations by 30% in seniors. Yet the law adds work requirements with exemptions that, in practice, are nearly impossible to navigate. Imagine a 72-year-old with arthritis trying to prove she’s “exempt” while juggling doctor’s appointments, transportation issues, and paperwork she can barely read. Many will lose benefits—not because they’re ineligible, but because the system is designed to fail them.
New York City’s Quiet Rebellion
While Washington pulls the plug, New York City is doing the opposite. In November 2015, Mayor Bill de Blasio announced the NYC 15/15 Initiative—a 15-year plan to build 15,000 units of supportive housing for the city’s most vulnerable: the homeless, the mentally ill, those aging out of foster care, people recovering from addiction.
The New York City Department of Housing Preservation and Development (HPD) administers the program, offering 15-year rental assistance contracts. Rent? No more than Fair Market Rent. Tenants pay just 30% of their income. The rest? Covered by city funds. Buildings are owned by trusted nonprofits, units are rent-stabilized, and on-site services—case managers, mental health counselors, meal programs—are built in. It’s not charity. It’s economics. A 2023 study by the Human Resources Administration found that each supportive housing unit saved taxpayers $18,000 annually by reducing emergency shelter use, hospital visits, and police interventions.
Why This Matters Beyond New York
What happens in New York doesn’t stay in New York. The city’s model proves that investing in stable housing and care at home saves money, improves dignity, and reduces strain on emergency systems. Meanwhile, federal cuts are forcing families to choose between paying for insulin and paying for a home aide. Some seniors are being discharged from hospitals into homeless shelters because no one will cover their care. Others are staying in nursing homes they don’t want to be in—simply because they have no alternative.
The contrast is stark. One side says: cut, restrict, punish. The other says: house, support, heal. And the data doesn’t lie. Cities like New York, Seattle, and Portland have shown that supportive housing reduces ER visits by up to 50%. But without federal backing, those programs remain islands in a sea of neglect.
What’s Next?
States are already bracing for Medicaid funding shortfalls. By early 2025, more than 20 states are expected to announce HCBS waiting list freezes. Advocacy groups like AARP and the National Association of Area Agencies on Aging are preparing lawsuits and public awareness campaigns. Meanwhile, New York City is on track to hit its 10,000th supportive housing unit by 2027—nearly halfway to its goal.
But without federal policy reversal, the gap between what’s needed and what’s funded will only widen. The question isn’t whether we can afford to help vulnerable seniors. It’s whether we can afford not to.
Frequently Asked Questions
How will Medicaid cuts affect home care workers?
Home care aides, who earn an average of $15.25/hour nationally, will face even deeper wage stagnation as states cut reimbursement rates. In states like Texas and Florida, some agencies have already reduced aide hours per client by 25% since the law passed. Many workers are quitting for higher-paying jobs in retail or logistics, leaving seniors without consistent care.
Who qualifies for NYC’s 15/15 supportive housing program?
Eligible applicants include nonprofit organizations or partnerships developing housing for homeless individuals, people with disabilities, or those exiting institutions like hospitals or jails. Applicants must have a tentative award letter from the Human Resources Administration’s EPIN: 09617I0006. Tenants must have incomes below 50% of the Area Median Income and require on-site support services.
Why are work requirements for SNAP harmful to seniors?
Seniors often face mobility issues, chronic pain, or cognitive decline that make fulfilling work requirements impossible—even with exemptions. The application process requires frequent documentation, internet access, and transportation to offices—barriers that disproportionately affect low-income older adults. Studies show nearly 40% of eligible seniors lose SNAP benefits under such rules, not due to fraud, but bureaucratic confusion.
What’s the long-term cost of cutting home care?
Every dollar spent on home care saves $3.50 in hospital and nursing home costs, according to the Centers for Medicare & Medicaid Services. When seniors are forced into institutions, the average annual cost jumps from $20,000 to over $100,000. Cutting HCBS doesn’t save money—it shifts costs to taxpayers in more expensive, less humane ways.
Can states override these federal cuts?
Some states, like California and Massachusetts, can use state funds to partially offset Medicaid cuts, but they’re limited by budget constraints. Most states can’t afford to fill the gap—especially after inflation and rising labor costs. Without federal support, even robust state programs will be forced to reduce eligibility or extend waiting lists, which already average 2–3 years in many places.
Is there any hope for reversing this law?
Legislative reversal is unlikely before 2026, but lawsuits challenging the SNAP work requirements and Medicaid cuts are underway in at least seven states. Grassroots pressure, combined with public testimony from seniors and caregivers, could force amendments in future spending bills. The real turning point may come in 2025, when the first wave of coverage losses hits the headlines.