These days, Paul Smith's 86-year-old mother cries all the time.
For years, the former Glen Burnie resident has gotten by, despite severe arthritis and a heart condition. But she's inconsolable, Mr. Smith says, knowing she could be forced by state budget cuts from the Catonsville nursing home that has been her home for 18 years.
Faced with what they say is an unfeeling state bureaucracy that could force hundreds of elderly Marylanders out of nursing centers they call home, the Smiths have decided to fight back. They've organized letter-writing campaigns to state officials and are making the rounds of the local media.
"She's so upset," said her daughter-in-law, Helen M. Smith. "She's constantly crying. It's awful to be 86 years old and not know where you'll be laying your head down at night."
The Ferndale couple learned last week that Elva Smith could be a casualty of state budget cuts aimed at Medicaid subsidies for nursing home patients.
As part of $7.3 million in cuts approved by the state's three-member Board of Public Works, nursing home residents with monthly incomes exceeding $1,055 -- about 1,900 people by state estimates -- would lose their subsidies.
Outraged by a measure that could force their mother from her home, the Smiths have distributed 2,500 letters so far -- through churches, their bowling league and a senior citizens expo -- and plan to circulate another 1,500.
"We felt as though there are all these people who are really being shafted," Mrs. Smith said. "As far as the future goes, we don't know when we'd be in the same boat."
Forced by state budget shortfalls to cut spending, Department of Health and Mental Hygiene officials say they have no choice but to impose Medicaid income limits. The subsidies account for 20 percent of all Medicaid costs, but go to only 6 percent of all Medicaid recipients.
"It's not a cut anyone likes having to make," said Nelson J. Sabatini, secretary of the Department of Health and Mental Hygiene. "After eight rounds of budget cuts and way over $1 billion, you reach a point where any cut you make is going to be a painful cut.
"But no one is going to be abandoned," he said. "No one will be thrown out of a nursing home and put on the street."
Mr. Sabatini said he is working to include a safety net to ensure there will be no arbitrary discharges. He also has abandoned plans to push the measure through as emergency legislation -- which, he said, removes the need for General Assembly approval.
Still, the Smiths fear the worst for Elva Smith and hundreds like her.
With a $1,330 monthly income from a $670 widow's pension and a $660 Veterans Administration pension, Mrs. Smith would have too much money to qualify for Medicaid. To stay in the nursing home, she'd be forced to pay an additional $1,600 per month, the Smiths said. Nursing homes charge an average of $3,000 to $3,500 a month.
But like most middle-class nursing home patients, she has no surplus income. She sold her assets -- all but $2,500 worth -- to qualify for Medicaid, and applies all but $40 of her monthly benefits to nursing home care. The Smiths say they can't afford to pay the difference, even if they split the bill among Elva Smith's three sons, two of whom have retired.
With health problems of their own and homes with no wheelchair accessibility, family members have no way to care for Elva Smith themselves.
"People who have worked and are entitled to retirement are penalized because they have a livable income," Mr. Smith said. "Someone on welfare would qualify, and a very rich person could pay for himself."
No one seems to know where displaced nursing home residents would go, though state officials have talked about moving residents in with family members and arranging for visiting nurses or adult day care.
But many patients are too frail or sick for community-based services, said Robbi-Lynn Watnick, director of government relations for the Health Facilities Association of Maryland.
"Some of these people have been in facilities five or six years," Ms. Watnick said. "The trauma, to move them, would probably kill them. This has been their home. This has been their family."
Joan O'Sullivan, managing attorney for the Legal Aid Bureau's Senior Citizens' Law Project, said the state may never realize the savings it expects. Lower-income people -- who require greater subsidies -- would simply replace middle-class residents, she said.
The state greatly underestimated the number of people who would be affected by the proposal, she said.
It's questionable whether nursing homes would be able, or willing, to absorb the additional costs that would be brought about under state cuts -- about $2,000 per person.
Ms. Watnick said one home estimated it would cost $500,000 to pay for 35 residents cut off from Medicaid.
"No one should be thrown out of a facility," she said. "But what each facility does is a facility-by-facility issue. Yes, nursing homes would probably end up somehow absorbing it, but how they would do it, we don't know."
Sen. Philip Jimeno, D-Brooklyn Park, a member of the committee that was to approve the regulations, has received hundreds of letters and phone calls against the plan. Though he has supported all state budget cuts for two years, this one wouldn't get his vote.
"We just can't in good conscience support the regulations in the current form," he said. "I'm not going to support anything [that would put] people out on the street."
His committee, chaired by Sen. Paula C. Hollinger, canceled Nov. 10 hearing on the original proposal and will reschedule a hearing once a revised version comes from the health department, he said.
If the regulations go through, the Legal Aid Bureau -- which represents clients in nursing homes -- would fight the limits case by case, Ms. O'Sullivan said. Federal law prohibits nursing homes from discharging patients without a safe and orderly plan, she said.
"I think there's a good chance it's going to go through unles people get together and block it," Ms. O'Sullivan said. "The state intends to do it unless it's stopped in some way."