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What next for MiCassa?

by Mary Johnson

The Medicaid Community Attendant Services and Supports Act, or MiCassa, has been introduced in Congress the last several sessions, never moving out of committee. And it will be introduced in the next session of Congress as well, says ADAPT's Bob Kafka.

It may not have passed Congress. But as a catalyst for change, MiCassa has been great, says Bob Kafka.

The bill, which ADAPT has been using as an organizing focus since the late 1990s, would establish "a national program of community-based attendant services and supports for people with disabilities, regardless of age or disability." It would change the currert Medicaid system of payments so the Medicaid-eligible individual could choose where to receive assistance -- in a nursing home or their own home. The Medicaid money would "follow the person" -- to be spent on services in a location of the person's choosing. (More about what MiCassa would do at the ADAPT website).

For years, the bill has been the rallying cry of ADAPT -- and they've gotten over 700 community and national groups to endorse the bill, with its concept of shifting Medicaid money away from its "institutional bias."

But it has never even gotten out of committee.

If you look at whether MiCassa has passed or not, you might say ADAPT's campaign has been singularly unsuccessful. But, says Kafka, as a catalyst for change, the MiCassa effort has paid off.

MiCassa may not have passed, but the focus on MiCassa has caused a lot of other things to occur, says Kafka. He ticks them off: the Bush administration's "Real Choice system change grants" funded at well over $100 million; "money follows the person" initiatives now going on all over the country; the shift in the "institutional bias.

"It used to be 80-20," said Kafka -- that is, 80 percent of the nation's long term services dollars went to institutions and only 20 percent went to services to let people live in their own homes. "Today it's 67-33", he says, a shift that amounts to about 10 billion dollars which used to go to institutions now going toward home and community-based services.

Kafka concedes that Real Choice grant dollars may not have always been well spent; that some states "are likely pissing it away in bureaucracy" as he put it. But, he argues, the Real Choice money coming into states is "keeping long-term-care reform high on the agenda in most states." Because of the grants, "there is some reform going on."

Advocates have all but given up on the Money Follows the Person Act. Once a separate bill, like MiCassa, the bill is now part of HR 1811 -- the House version of the Family Opportunity Act. Kafka says the Bush administration had supported the bill, but planned to find the dollars to fund it by reducing the federal match for another Medicaid program, something Kafka called "totally unacceptable."

Although legislative initiatives have stalled, the changes that have already occurred in the policy area, in the states, "show that we're having an effect," Kafka said.

He pointed to ADAPT's success last month in getting the National Governor's Association to agree to consider a resolution at its next meeting committing the governors to "support community-based long-term term services and supports" and "aggressively implement" the 1999 Olmstead Supreme Court decision, which ruled that people must be allowed by law to receive state services in the "most integrated" setting. (More about the resolution.) "The reason we made such a big deal over the resolution is because it pretty much encompasses what needs to be done in terms of shifting priorities in long term services and supports at both the state and federal level," said Kafka.

"We need folks at the state level to keep pushing" for reforms, he continued; for a shift from institutional to in-home services, said Kafka. "ADAPT's strategy has always been to have things bubble up [from the state to the federal level]. We need to keep pushing to get things shifted."

"It's like turning the Queen Mary," he said. "It's so big that when you're on it you don't realize it's turning. " ADAPT's work -- in focusing on MiCassa -- has already accomplished a lot of what MiCassa calls for, without the bill ever seeing a vote.

Still, Kafka says the Congressional effort must continue. "Regardless of what else happens," he says, "MiCassa has been recognized by hundreds of groups as the first line of reform." He says they will be working to get the bill introduced "very early" in the next session of Congress -- right after the inauguration, "or at least by early February, 2005."

Posted August 2, 2004

Mary Johnson edits Ragged Edge online.

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