HARRISBURG — In over five hours of questioning, House lawmakers drilled down on a vast array of issues under the purview of Pennsylvania’s largest – and most expensive – agency, the Department of Human Services.

Armed with a binder containing hundreds of pages of details and statistics, DHS Secretary Dr. Valerie Arkoosh and her team fielded questions about the care the state provides to its vulnerable populations, including seniors, those living with disabilities and low-income families.

According to Republican Chair Jim Struzzi, the department’s total budget request is about $21.1 billion, an increase of $1.96 billion.

With potential federal budget cuts looming, many are concerned about the future of social programs like Medicaid. Republican congressional leadership has proposed a cut of $880 billion through 2034, which is largely expected to come from Medicaid and CHIP. The health care programs are administered by the Arkoosh’s department but largely funded by the federal government.

Estimates from the Center for American Progress, a liberal policy organization, indicate an average $2 billion reduction per congressional district over nine years, with enrollment reductions ranging from 25,000 to 84,000 people per district.

According to Arkoosh, nearly 3 million people are currently on Medicaid throughout the state and over a third of that number are children. Medicaid is the payer of last resort, meaning that it only covers costs third party insurance won’t.

She says cuts to Medicaid would result in hospitals, who cannot refuse emergency services, incurring a huge uptick in uncompensated care. Especially in rural areas where hospitals are already struggling to keep their doors open, this could rapidly lead to reductions in services and even closures.

Even without federal concerns, legislators are in a tight squeeze. Arkoosh says this was a lean budget year when hard decisions had to be made about where to request funding and where to make cuts. Several times legislators expressed disappointment over programs with flat funding in the proposal.

For instance, Rep. Emily Kinkead, R-Bellevue, inquired about rape crisis centers which have been flat-funded for the sixth year in a row despite a 28% increase in cost and an increase in demand for the services.

Arkoosh shared her concerns and assured her that they were doing what they could to leverage options like telehealth in the absence of further funding.

Yet, Struzzi noted that the budget has continued to rise from years past. The lion’s share of the increase is going toward maintaining Medicaid coverage, which necessarily rises as costs do.

“I understand the important role that human services play in our communities for our families, for our young people, for our elderly people, but I think we have a fundamental math problem with this budget,” said Struzzi.

The state has no choice but to provide the necessary funding for Medicaid, and the $150 million in additional proposed spending for department programs represents a very small increase relative to the big picture.

Arkoosh noted that the programs her department is asking the legislature to fund and support are aimed at ultimately reducing costs.

One major example of this is home care aimed at keeping seniors in their communities. Federal regulations explicitly prohibit states from using Medicaid for room and board, but nursing care is nevertheless an entitlement the state must cover in the event someone can no longer live at home. The costs of assisted living or nursing home care are far higher than those of home care, so ensuring the availability of these services is a top priority.

The state has struggled to get other services it sees as essential to “21st century medicine” covered by Medicaid. Covering doulas who provide support during pregnancy and childbirth has been a success of the administration, while covering community health providers who build trust and are effective in navigating healthcare alongside individuals remains a work in progress. Bending federal systems like Medicaid, which was established in 1965, to a new model of care focused on prevention and holistic approaches, remains a challenge for the department.