Patient Protection and Affordable Care Act (PPACA) and the included Community
Living Assistance Services and Support Act (CLASS) have great potential to be
catalysts for a more inclusive and community based health care system. The attention to covering all citizens will,
if implemented appropriately, be a real change for many who have been unable to
obtain or afford health coverage due to pre-existing conditions, including
disability. While the act appears to be
making needed changes, the real work is only beginning. The thousand pages of law will be turned in
to many more pages of regulation at the agency level. Though some regulatory provisions have been
completed (see https://www.cms.gov/LegislativeUpdate/downloads/PPACA.pdf),
many more have yet to be started. It
will be vital that the community of persons with disabilities and their
advocates participate in the regulatory process in order to ensure appropriate
of discrimination on the basis of pre-existing conditions, no lifetime cap on
benefits, increased access to community and home-based services, and mental
health inclusion in basic packages are frequently cited as some of the most
positive components of the law. While
these changes are viewed as positive in general, concerns remain about how the
changes will affect cost of policies and business ability to provide coverage
through employment when their coverage is impacted. The recent one year exemption to the
provisions given to McDonald’s is one of the most prominent examples of the impact
of these concerns. CLASS also may have
hurdles to overcome to be implemented in a way that is meaningful. Persons must have paid in to CLASS for five
years before they can receive coverage.
In addition, there are work requirements which may preclude some classes
of persons with disabilities from fully participating in the plan. One will only be able to see the full impact
of some of these provisions over time. Participation
in the regulatory process through response to calls for public comment, active
lobbying of appropriate agencies, grassroots movements, and any other available
process will be necessary to have input in final regulations. Additionally,
states will be responsible for creating their own Insurance Exchanges as required
by the law or will be included in the federal exchange. Advocacy
at the state level will also be necessary to the process.
portions of the PPACA will be of particular importance to the community of
persons with disabilities. A few of the
key sections providing advocacy opportunities will be outlined below.
of the early regulatory tasks have been definitional. One section of the law required creation of
uniform definitions for items such as “preexisting condition” and “lifetime
limits” including how they are implemented and any prohibited behavior. These regulations are now complete. The Consortium for Citizens with Disabilities
commented on the interim regulations.
Others were also involved and will need to remain involved throughout
the regulatory process if we are to ensure inclusion and appropriate coverage
for persons with disabilities.
for certification of “Qualified Health Plans” under the PPACA will be created
under Health and Human Services regulations.
While there are 8 specific criteria set out by the PPACA which must be
followed, there is much which will be determined during the regulatory
process. As the process of defining these plans takes
place, advocates will need to be able to articulate which services are most
critical to the disability community.
When compromise is needed, what can reasonably be compromised without
giving up core services and what are non-negotiable services? When groups within the advocacy community do
not agree, how are these differences handled so that the policy makers are not
confused? Some of the needed services
may have a community based component.
PPACA has been written with an emphasis on these services and along with
possible advocacy in the Qualified Health Plan component, there will be
additional opportunity for advocacy under the community based services section
of the law.
attention to community based services in the PPACA is an important
achievement. How the law is actually
implemented will make the difference in whether or not the emphasis on
community based services is merely aspirational or truly achieved. Health and Human services will be
promulgating regulations designed to (1) “allocate resources for services in a
manner that is responsive to the changing needs and choices of beneficiaries
receiving noninstitutionally-based long-term services and supports (including
such services and supports that are provided under programs other the State
Medicaid program), and that provides strategies for beneficiaries receiving
such services to maximize their independence, including through the use of
client-employed providers”; (2) “provide the support and coordination needed
for a beneficiary in need of such services (and their family caregivers or
representative, if applicable) to design an individualized, self-directed,
community-supported life”; and (3) “improve coordination among, and the
regulation of, all providers of such services under federally and State-funded programs.” 
All of these goals are important. The specifics of what will be required of
payers in relation to these goals will be even more important. Careful participating in the regulatory
process will be required to ensure appropriate implementation.
regulations written to implement the CLASS act will also be important to
ensuring the most access to community based services. CLASS will be a voluntary program allowing
persons to pay premiums and receive money to pay for home based services. The PPACA calls for the design of three
possible plans for consideration as the final program. Advocates will need to work to ensure
reasonable plan design and implementation.
are additional sections which will require attention, but these are some of the
key provisions providing a need for advocacy over the next few years.
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