In August 1981, then-President Ronald Reagan signed a bill into law that allowed the development of state-level programs to help disabled people live outside institutions like nursing homes. Known as Home and Community-Based Services (HCBS) waivers, the programs—now in their fourth decade—are funded by Medicaid and run by each individual state. With potential cuts to Medicaid a priority for the Trump administration, the future of HCBS remains in limbo. Donald Trump’s recently confirmed Treasury Secretary Scott Bessent has refused to directly answer questions about whether he’d fall in line with attacks fielded by Republican politicians and Project 2025 by offering a recommendation to cut Medicaid.
Reagan couldn’t be described as an advocate for disabled people’s rights—just over a year into his first term, 130,500 people had already been dropped from Social Security Disability Insurance, then and now a lifeline for millions. Like Donald Trump, Reagan wanted to slash government spending at the expense of Americans’ wellbeing. But while the politics of the time forced Reagan’s GOP to field a compromise with some benefits for disabled people—which yielded HCBS—the Trump White House hopes to gut even that, leaving hundreds of thousands of people, if not millions, without the option of community care.
Today, roughly 4.5 million people use Medicaid-funded HCBS as an alternative to institutionalization; the waivers help pay for home healthcare workers, durable medical equipment, career coaching, case management and other services. No one claims that the program is perfect—but most criticism has come on the basis of shortfalls, not overspending. More than half a million disabled people remain on waitlists for HCBS, often waiting years for a waiver, and inconsistent requirements across states can make the process confusing and challenging.
“It’s a bit of a mix between racism and ableism that believes that certain types of people are undeserving of assistance,” said Mia Ives-Rublee, senior director of the Center for American Progress’ disability justice initiatives, of ongoing attacks on Medicaid.
Ives-Rublee said that Project 2025 includes a push to end Medicaid exception waivers—programs that allow states to modify and add to standard Medicaid services, which “specifically implies HCBS funding”—on the grounds that the government is spending too much money on them.
