Act calls for care choice

Bob Kafka outlines the Medicaid Community Attendant Services Act, MiCASA. The bill would allow individuals the choice to use their entitlements for community-based services (personal assistance services). Internet publication URL:

by Bob Kafka, 1999

Imagine you have a stroke, your child has a car wreck or your newborn has physical and/or mental disabilities. What do you do? Where do you go? What kind of services are available?

Accessing community-based services for the growing number of people with disabilities, older Americans and their families is one of the most critical issues facing this country.

The current public system of support services was designed more than 30 years ago based on a medical model of service that held that people with disabilities, regardless of their age, should receive services in nursing homes or some other congregate institution.

This system is primarily funded by Medicaid through Title XIX of the Social Security Act. It has institutional services as an entitlement and community-based programs as the alternative. Though everyone involved dislikes the program - families, people with disabilities, providers and government bureaucrats - it has been a difficult program to change. Last Congressional session Speaker Newt Gingrich and Minority Leader Dick Gephardt introduced HR 2020, The Medicaid Community Attendant Services Act, MiCASA.

MiCASA was Congress' attempt to take a beginning step in reforming the institutionally biased Medicaid system by allowing individuals the choice to use their entitlements for community-based services. Though getting 75 cosponsors and a hearing in the Commerce Committee's Health and Environment Subcommittee, the bill bogged down in the politics of the 105th Congress.

Advocates for people with disabilities and elderly people have worked together to get a second version of the bill introduced in the 106th Congress. The new version will be called The Medicaid Community Attendant Services and Supports Act of 1999, or MiCASSA.

MiCASSA has been restructured to include a Purpose section that makes the philosophical foundation of community services much stronger. The Service section remains essentially the same, but the addition of the words "and Supports" to Attendant Services makes it clearer that MiCASSA serves people of all disabilities and ages. Those individuals eligible for institutional services will be able to choose to have those dollars used for community services as in the old MiCASA.

The new bill will also have a "Real Choice Systems Change" section giving states financial incentives to move from the current institutionally biased system to one that offers community-based services as a priority. In addition there will be an optional Medicaid "buy-in" section that will allow people of higher income (ineligible for Medicaid) to "cost share" and receive services while paying a portion of the costs.

MiCASSA will not be an easy bill to get on the President's desk. The disability and senior communities are planning a grassroots campaign to educate Congress and the general public on the need for reform of the long-term services portion of the Medicaid program. MiCASSA is the key to open the door to reform of the complex, long-term care system.

Bob Kafka, from Austin, Texas, is a national organizer for ADAPT, a disability-rights group advocating for community services (