This article analyzes how Medicaid’s home and community-based services (HCBS) waivers support millions of disabled people and older adults. It also explores why proposed federal cuts to Medicaid and FEMA could undermine disaster readiness, community-based care, and the workers who deliver essential services.
The article highlights how climate-driven disasters intensify existing vulnerabilities. It emphasizes why both policy and funding decisions in Washington matter for people relying on HCBS across the United States.
HCBS Waivers: A Lifeline for Community-Based Care
In 1981, Congress created Medicaid home and community-based services (HCBS) waivers that now help about 7 million disabled people and older adults live outside institutions. These waivers are designed to coordinate a spectrum of supports—personal care, respite, transportation, and community integration—through local providers.
The aim is to keep people in their homes and communities rather than in facilities. The model has been a cornerstone of patient-centered, cost-effective care that preserves independence and dignity.
Yet these providers often operate on thin budgets and face limited flexibility to invest in disaster preparedness. As climate-driven extremes—heat waves, hurricanes, wildfires—become more frequent, the resilience of HCBS networks is increasingly tested.
The ongoing challenge is how to fund readiness, disaster response, and ongoing care without destabilizing a system already stretched thin.
Disaster Resilience in a Changing Climate
When disasters strike, HCBS providers are asked to adapt quickly, frequently without dedicated funding for emergency transportation, overtime, or hazard pay. Payment models that require preapproved, person-centered plans for reimbursement can delay or deny coverage for unplanned disaster-related costs.
This leaves vulnerable Medicaid recipients at higher risk during crises. The result is a fragile balance between delivering essential supports and sustaining the organizations that provide them.
Policy Landscape: Federal Cuts and Coordination Gaps
The current policy conversation centers on proposed federal cuts to Medicaid and FEMA that could weaken the federal coordination crucial to HCBS and local emergency planning. Critics warn that reducing federal resilience programs and staffing calls into question the ability of states and providers to scale care during extreme weather events or public health emergencies.
The erosion of centralized support—once a mitigating force in disaster planning—risks leaving states to patch gaps with already-stretched resources.
Who Bears the Burden?
Medicaid recipients in disaster-prone states, including many led by Democrats such as California and New York, stand to lose continuity of care if funding shifts away from resilience and emergency preparedness. Home care workers, who are often low-paid—more than half earn under $20/hour in 34 states—face greater burdens during emergencies, with limited support for transportation, overtime, or hazard-related costs.
The net effect is increased risk for vulnerable populations just when disaster response must be strongest.
State Actions and Best Practices
Some states are already taking steps to shore up HCBS during crises. For example, California coordinates regional centers with HCBS providers during wildfires to preserve continuity of care and protect vulnerable residents.
In another concrete measure, seven states now cover air-conditioning costs for HCBS recipients during extreme heat, an acknowledgment that climate conditions directly affect health and safety at home. These targeted policies demonstrate what can be achieved with state-level leadership and tailored funding, even as broader federal gaps persist.
What Needs to Happen Next
Advocates argue for restoring federal resilience programs and redirecting funds to support HCBS emergency planning and worker wages.
Without this investment, the nation risks a shift away from community-based care when it is most needed, jeopardizing independence and safety for millions who rely on these services.
The path forward requires both policy reform and sustainable investment at multiple levels of government.
- Restore federal resilience funding for HCBS and emergency planning
- Make reimbursement models flexible enough to cover unplanned disaster expenses
- Increase wages and support for home care workers to attract and retain a skilled workforce
- Strengthen coordination between federal, state, and local agencies to align disaster response with community care
- Expand climate disaster preparedness within HCBS programs and infrastructure
Here is the source article for this story: Home care wasn’t ready for the climate crisis—even before Trump’s Medicaid and FEMA cuts