As the country settles into a new administration controlled by the Republican Party, one of the largest campaign and policy promises that Americans have been given is that the Affordable Care Act, also known as Obamacare, will be repealed. Proponents of repeal have listed a number of reasons for their desire to get rid of the law, including rising premiums, rising costs of medical care, and less control and fewer choices for health care consumers.
While some Republicans have acknowledged successful parts of the bill, such as provisions that outlaw discrimination against people with pre-existing conditions, or allow children to stay on their parent’s insurance until the age of 26, it looks as though Republicans would like to repeal the law outright as opposed to taking a piecemeal approach that could leave some of these popular provisions in place. The threat of total repeal has many in the disability community and many with long-term health conditions concerned.
Although House Speaker Paul Ryan said during the introduction of the repeal bill that “our goal is to ensure that patients will be in control of their health care and have greater access to quality, affordable coverage,” the repeal will do the opposite for millions of Americans. By taking away essential provisions created under the ACA, a repeal will be stripping liberties from millions of Americans by taking away their ability to purchase affordable health care plans with pre-existing conditions, repealing access standards for medical equipment, and throwing away the Community First Choice Option (CFCO), in Section 1915(K), which prioritizes offering home- and community-based services (HCBS) to Medicaid beneficiaries.
Repealing the CFCO is a sign that repeal proponents have not read the entire law, and that they do not recognize the devastating implications that this repeal could have on millions of disabled Americans. And unfortunately, according to the recently-leaked GOP discussion draft to repeal the law, Republicans would like to sunset the CFCO provision on January 1, 2020.
What is Community First Choice?
What is Community First Choice? CFCO was created by the ACA to make it easier for Medicaid beneficiaries to receive and manage home- and community-based services. If a state chose to implement CFCO, it receives increased Federal funding to provide these supports to beneficiaries. This enhanced Federal sharing incentivizes the states to adopt CFCO. It offers certain mandatory services, including assistance with activities of daily living (ADL), instrumental activities of daily living (IADL), health-related task assistance, and backup systems. CFCO can cover everything from personal care attendants who help disabled people carry out basic living tasks such as daily grooming needs and meal preparation, to home health care services, and even assistive technology.
In addition to CFCO, the ACA also expanded a program called The Money Follows the Person, or MFP, which helps disabled people move from institutional settings to home-based settings. According to the National Council on Independent Living, MFP has been adopted in 47 states, and CFCO has been adopted in five states. Together, these programs have significantly expanded people’s financial ability to stay at home or leave an institutional setting.
CFCO actually offers a more significant level of choice and liberty to disabled Americans. Those who receive these services are assessed during qualification as needing “an institutional level of care,” meaning that without home- and community-based services, they would be forced to live in a nursing home or other long-term institution. The existence of these services allows them to live more independently and stay in their own homes. Furthermore, CFC aims to give Medicaid beneficiaries a greater hand in directing these services. One of the required services that all states electing to use CFCO must offer is training on how to hire, manage, and fire attendants for care. Those who use HCBS have a much greater hand in choosing who gets to provide their care. While Speaker Ryan and other proponents of the ACA’s repeal claim that the ACA has given health care consumers fewer choices for health care services, the exact opposite is true for millions of Americans who qualify for CFCO.
What Will Repeal Mean for CFCO?
Prior to the ACA, and in states that have not chosen to implement CFCO, states offered waivers so that people could receive the supports they needed. These waivers were and are inferior to CFCO because they cap services, have waiting lists, and can limit services to certain sections of the state.
The repeal of the ACA has a simple but devastating effect on the medical and lifestyle choices,and liberty, of millions of Americans. Without CFCO and MFP, access to home- and community-based services will be significantly reduced, and those who require an institutional level of care will be far less financially capable of receiving that care in their homes and communities. More and more disabled citizens will be forced into institutional settings that are much more restrictive, including intermediate care facilities (ICFs), nursing facilities, and institutions for mental health. They will lose these new options that give them greater control over the services they receive. In California alone, it is estimated that 500,000 people could see a reduction in receiving long-term services and supports (LTSS).
No law is perfect, and the Affordable Care Act may certainly have some provisions or implications that need to be examined and fixed so that it can benefit more Americans. However, a repeal of the law could have a catastrophic effect on the millions of disabled citizens who want and deserve the same opportunity to live in their homes as anybody else. By repealing the law completely without saving these provisions, proponents of repeal will actually do the opposite of what they are claiming, and will give a significant number of Americans less control over their medical care, less access to vital services and supports, and fewer opportunities to live in their communities.