A Democratic proposal with the potential to transform life for the elderly and people with disabilities may get less than half the funding its champions envisioned, according to multiple sources involved in Capitol Hill deliberations.

The proposal would dramatically strengthen federal support for what are known as home- and community-based services, or HCBS for short. Its a catch-all phrase for programs that make it possible for elderly and disabled Americans to live on their own, outside of institutions. In practice, it can mean everything from caregivers who help with hygiene to nonprofit organizations that help with housing and job placement.

President Joe Biden and Democratic leaders have said repeatedly that they want the home and community proposal to be part of the large spending legislation they are now writing and hope to pass this year. But they are saying the same thing about other initiatives, like proposals to add dental coverage to Medicare and get Medicaid to people in Republican-led states that havent expanded their programs.

Fitting all of these ideas into one piece of legislation is proving difficult, especially with more conservative Democrats agitating to make the package smaller and less expensive. Leaders have responded by downsizing some of the component pieces and, at the moment, the home and community proposal appears to be in line for one of the more substantial cutbacks.

Instead of the $400 billion over 10 years that Biden and congressional leaders proposed initially, they are talking about spending somewhere in the range of $150 billion to $250 billion, according to several sources on and off Capitol Hill who requested anonymity in order to speak candidly about the ongoing negotiations.

The situation is fluid, with multiple conversations involving Congress, the White House and outside groups happening simultaneously. Even a partially funded version of the home and community initiative would represent a historic increase, enough to have a substantial effect on the lives of everyday Americans.

But especially at the lower funding levels under discussion, advocates say, it would be difficult to achieve the proposals intertwined goals: making sure the services are available to everybody who needs them while raising caregiver pay enough to attract and retain well-qualified workers.

A Legislative Version Of The Hunger Games

Helping millions of older and disabled Americans to live outside nursing homes and other large institutions has been a goal of government policy for roughly half a century.

But that goal remains elusive. Hundreds of thousands of people are on waiting lists for programs because states have capped enrollment, with potentially hundreds of thousands more not even bothering to get on the lists because the waits would be so long. Still others cant find caregivers because low pay has created labor shortages. The quality of programs also varies wildly.

A common element in these problems is limited funding from Medicaid , which states manage with the help of federal funds and in accordance with federal guidelines. Under legislation co-sponsored by Sen. Bob Casey (D-Pa.) and Rep. Debbie Dingell (D-Mich.), the federal government would offer the states extra Medicaid funds to support home and community programs. In exchange, states would have to meet certain conditions, like raising caregiver wages.