In 1981, Congress amended the Social Security Act to help millions of disabled people and older adults move out of institutions. Through home and community-based services waivers (HCBS), some 7 million Medicaid recipients now receive support that lets them stay in their communities. But after years of neglect under both parties, experts fear that sweeping cuts to both Medicaid and FEMA—especially under the GOP’s most recent budget bill—may be the final straw for the often small, privatized, and often budget-strapped providers behind that care.

That’s especially true as heat waves, hurricanes, wildfires and other climate events ramp up globally: almost a tenth of Medicaid recipients rely on HCBS, many in climate disaster–prone areas that have been targeted by the Trump administration for cuts. The administration’s attacks on Medicaid-based home care have focused on states like with Democratic governors like New York, California, Minnesota and Maine, all of which face risks from extreme weather—but almost all states are expected to cut home care funding as a result of federal Medicaid cuts.

HCBS providers, which range from smaller nonprofits to large, private equity–backed organizations, are essentially the coordinators of many Medicaid recipients’ independent living. Few have the flexibility to pour more funds into advance planning for growing risks like fires, floods, and hurricanes—a role that FEMA would once have done more to shoulder.

But the Trump administration has moved to, in effect, dismantle the agency, rolling back key services like FEMA’s Building Resilient Infrastructure and Communities program and moving to lay off thousands of workers (a plan that was put on hold), including those who could coordinate with home care providers........

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