Born with cerebral palsy, Jennifer McPhail relies on a home health aide to help her get dressed for work and ready for bed at night.
Her motorized wheelchair keeps her active, working as an organizer with a disability rights group in Austin, Texas, and volunteering to help people find housing and to staff hurricane shelters. She now fears deep cuts in the state's Medicaid spending will prevent her from living independently.
It's a concern facing families across the country as states with gaping budget deficits cut home health services that help keep the elderly and disabled out of nursing homes. States are reducing how much time a nurse can spend making house calls and ending meal deliveries for the homebound.
Many also are gutting adult day care programs that give seniors a safe place to spend their days while their relatives are at work.
Aging and disability services in three out of four states have been reduced over the last two years or face cuts, even though demand is increasing.
Texas lawmakers underfunded Medicaid by nearly $5 billion in the state budget, a move that home health advocates say leaves the elderly and adults with disabilities unsure how their care at home will be provided.
California eliminated funding for about 330 adult day centers, a move that will affect some 35,000 seniors who use them for medical care and socializing. Lawmakers are hoping to restore about $85 million to transition seniors into an as-yet undetermined alternate program -- about half the amount cut from the budget.
Minnesota is considering cuts to home health aides and a program that allows disabled people to live on their own.
With each cut, the ability to live at home becomes more difficult.
"You end up losing control over your decisions," said Neil Johnson, executive director of the Minnesota HomeCare Association.
About 12 million people receive home health services nationwide, according to the National Association for Home Care and Hospice.
Home health services are an easy target for budget-cutters because they are not required by federal law, have been subject to fraud and don't have deep-pocketed special interests advocating for them. But down the road, steep cuts in these services eventually could cost states more money if they end up pushing more people out of their own houses and into nursing homes that would require taxpayer subsidies.
"Just because you cut the budget doesn't mean their needs go away," said Anita Bradberry, executive director of the Texas Association for Home Care & Hospice Inc.
Medicaid, the state-federal program that pays for medical and long-term care for the poor and disabled, is required to help fund nursing homes but not home care and community services.
Because the programs are not required, most states first look at cutting home health care funded through Medicaid, even though such programs are much cheaper than nursing homes.
The price of an adult day health center is $67 a day on average, compared with $229 a day for a private room at a nursing home, according to a 2010 survey released by insurance company MetLife Inc.
Overall, Medicaid spending on nursing homes came to $46.5 billion in 2007, the latest figures available, while home health services cost $6.3 billion, according to the U.S. Department of Health and Human Services.
Before the recession, states actually expanded home health programs because they are less costly. But now, with so many states facing billion-dollar deficits, lawmakers say they have no choice but to cut Medicaid spending, the second-biggest spending item for states behind education.