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Medicaid funding skewed

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By Susan L. Parish

People with disabilities overwhelmingly prefer to live in their own homes in their own communities, and not in nursing homes or institutions.

And yet for the more than three decades Medicaid has been funding long-term care for people with disabilities, nursing homes and institutions have been the predominant form of such care.

Currently, $41 billion in Medicaid funds go to nursing homes and institutional care while just $10.5 billion support people living in their own communities.

Why are just one-fourth of Medicaid’s long-term care dollars directed to the community services people with disabilities prefer?

Because nursing homes are a mandatory service: States that receive federal Medicaid funds MUST provide nursing home care.

Community services, by contrast, are optional: States do not have to provide them in their Medicaid plans, and the demand for community care far outstrips supply in nearly every state.

What can be done to address this gross imbalance?

Pass MiCASSA, the Medicaid Community Attendant Services And Supports Act.

MiCASSA would give people with disabilities real choice in the type of long-term care services they receive because it would reform the funding process.

Currently, states typically contract with nursing-home service providers that subsequently receive Medicaid funds for each Medicaid recipient served.

Under the proposed MiCASSA bill, control over services is given to individuals with disabilities.

MiCASSA would make personal attendant services a mandatory Medicaid service. These services enable people with disabilities to direct their own care in their own homes.

Individuals would be eligible for services depending on their unique, individual needs. People with disabilities will agree to the service plans that direct their care, and be given the ability to hire, train and fire attendants.

For people whose impairments limit their ability to direct their care, MiCASSA authorizes representatives, in the form of a guardian, family member or friend, to assist in directing the care.

MiCASSA allows consumers to choose from an array of service models, and includes important quality assurance protections.

Is MiCASSA revolutionary?

Absolutely. It will indelibly change the lives of people with disabilities incarcerated in nursing homes and institutions.

It will address some of the unfulfilled aspects of the Americans with Disabilities Act, which was passed in 1990 to give people with disabilities civil rights.

The ADA’s civil rights protections are merely hollow promises if people with disabilities have no say over where they live, and are forced into institutions.


Susan L. Parish is an assistant professor at the School of Social Work at the University of North Carolina at Chapel Hill.

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