LOS ANGELES - 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.
"What it says to me is that the state doesn't value the lives of people with disabilities," said McPhail, 39. "A lot of people are going to be hurt in a very intimate way."
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 Home-Care Association.
About 12 million people receive home health services nationwide, according to the National Association for Home Care and Hospice.
Adult day care centers provide another avenue for the frail and their caregivers, but those programs also are on the wane.
Several states have been chipping away at adult day care programs over the last year and some have eliminated them, even though the number of facilities has grown by a third since 2002, according to a 2010 study from the National Adult Day Services Association.
Mary Nonnette, who lives in Hawthorne, Calif., isn't sure how she will take care of her mother if she is no longer eligible to stay at one of the centers in Los Angeles.
Nonnette, 67, said she does everything for her 87-year-old mother "except breathe, really," and that she has provided the care alone since her husband suffered a paralyzing stroke in December. The only time she's free to visit her husband is when her mother is at the center.
"For four hours, three days a week, I don't have to worry," Nonnette said.
It's not just home health services for seniors that are under attack.
Washington state slashed how many hours it will reimburse professional caregivers who work with the disabled.
The changes that began this year mean home health worker Deborah Osborn, of Tacoma, Wash., had to cut 19 hours from the time she can spend with a 27-year-old developmentally disabled woman.
The state now limits her to 40 hours per week. That might still sound like a lot of time, but Osborn's client relies on her for assistance with everything from grocery shopping to dressing herself.
As a result, Osborn can help the woman shower just twice a week instead of three times. Laundry is limited to twice a week and grocery shopping is down to once a month. Any more state cuts will force the woman out of the home she shares with a family member, but it's too dangerous for her to live by herself, Osborn said.
"She's going to suffer the consequences," she said.
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 generally 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.