Sen. Harkin — The Affortable Care Act

Circa 2012

Dear ABILITY readers,

The Affordable Care Act includes a number of provisions intended to benefit individuals with disabilities. One of the most important of these is the Community First Choice Option, which represents a significant step toward removing institutional bias in the Medicaid program.

Recently, the Center for Medicare and Medicaid Services published the final rule for implementation of the Community First Choice Option. It is a new, state-optional program that will provide home- and community-based attendant services and supports for certain individuals with disabilities. They must be eligible for an institutional level of care under Medicaid. In states that adopt the Community First Choice Option, eligible individuals will have the choice to receive attendant services and supports within their home and community, rather than in a nursing home or other institutional setting.

As an incentive to adopt the program, states that select the Community First Choice Option will receive increased federal matching funds—an additional 6 percent—for the costs associated with the program.

Many of you may remember our prior legislative efforts to remove the institutional bias in the Medicaid program, through many years of advocacy on MiCASSA (Medicaid Community Attendant Services and Supports Act), and its successor, the Community Choice Act. The Community Choice Option incorporates all the essential pieces of these bills; the only difference is that the Community First Choice Option is a state-optional program, rather than a mandatory one.

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The services available through the Community First Choice Option include services to assist individuals with activities of daily living (ADLs), instrumental activities of daily living (IADLs) and health-related tasks through hands-on assistance, supervision or cueing.

ADLs include eating, toileting, grooming, dressing, bathing and transferring. IADLs include meal planning and preparation; managing finances; shopping for food, clothing and other essential items, as well as performing essential household chores. Health-related tasks are defined as those that can be delegated or assigned by licensed health-care professionals under state law to be performed by an attendant.

These are services that are provided by an aide to help with everyday tasks that most people take for granted. For many people with disabilities, assistance with these tasks makes a crucial difference between whether they are able to live an inclusive life within the community or an isolated life in a nursing home or other institution.

I often think of my nephew, Kelly, who became a paraplegic while serving in the Navy. He receives attendant services through the Veterans Administration that allow him to get up in the morning, go to work, operate his own small business, pay taxes and live in his own home. Now, with the Community First Choice Option, many others will have the same opportunity as Kelly to receive these services, be independent and pursue a career.

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It was in Olmstead vs. L.C. that the US Supreme Court held that the unnecessary institutionalization of individuals with disabilities constitutes discrimination, while the Americans with Disabilities Act (ADA) requires that individuals with disabilities be given the choice to receive their long-term services and supports in home- and community-based settings, rather than only in institutional settings.

However, the problem has been that under current law, Medicaid is required to pay for nursing-home care or other institutional care for an individual with a disability, but the state has no similar obligation to pay for the same person to receive his or her care at home. This has made the promise of the Olmstead decision hollow for the residents of many states.

While most states provide some home- and communitybased services through Medicaid waiver programs, these programs are usually limited—with caps for costs, caps for the number of people served and limits on the specific disabilities that are covered.

The Community First Choice Option is a real opportunity to change that. States choosing the Community First Choice Option will be required to provide homeand community- based attendant services and supports to all eligible individuals. The services would be provided regardless of age or disability, in the most integrated setting appropriate for the individual, and would be available statewide for eligible individuals.

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But the Community First Choice Option is an optional Medicaid program—not a mandatory one. Each state will need to make a decision on whether to take it up. That’s where I need your help—to make sure that officials in each state know about the importance of choosing the Community First Choice Option. You can play a powerful role in persuading as many of your legislators as possible to participate in the Community First Choice Option.

The costs of taking this path would be mostly offset by the benefits of having people with disabilities who are employed, paying taxes and contributing to the economy, especially given that the federal government is paying an increased share of the costs of the program, compared to other Medicaid services. With appropriate community services and supports, we can fulfill the great goals of the ADA: equal opportunity, full participation, independent living and economic self-sufficiency.


Senator Tom Harkin

Senator Tom Harkin (D-IA) is Chairman of the Senate Health, Education, Labor and Pensions Committee

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