Sen. Tom Harkin (D-IA)

More Medicaid funds would flow toward home- and community-based services rather than nursing homes under legislation introduced Tuesday by Sen. Tom Harkin (D-IA).

The “Community Integration Act” is intended to speed up implementation of the Supreme Court’s Olmstead ruling, Harkin said when announcing the bill at a hearing of the Senate Health, Education, Labor & Pensions (HELP) Committee, which he chairs. Olmstead stated that certain nursing home residents with disabilities have a right to live in home- or community-based settings if they have the ability, and it is their preference.

Even though the Olmstead decision was handed down 15 years ago, 200,000 working-age people remain “unfairly segregated” in nursing homes, according to a report prepared last year by Harkin’s staff. This is partly due to “nursing home bias” in Medicaid, which must pay for institutional care but often does not have to pay for home- or community-based care for a given beneficiary, Harkin said at the HELP Committee hearing.

His bill would address this by “clearly allowing” Medicaid to fund nursing home-level care for people living at home or in the community, Harkin explained. The bill also would set requirements regarding how states determine people’s eligibility for HCBS.

The measure would prohibit states from making people ineligible for home- or community-based care due to a “particular disability,” according to a HELP Committee press release. This topic came up during the hearing Tuesday afternoon. Harkin asked panelists whether people with complex disabilities, such as people who cannot speak, should be a focus of transition efforts or whether they generally are better off in institutional care.

While frequently it is possible to create a care plan that would allow these individuals to move out of nursing homes, it can be difficult to implement such a plan and “get the supports and services in place for these people outside of a facility,” said Gail Godwin, executive director of Shared Support Maryland, which provides services to people with significant developmental disabilities.

Nursing home staff sometimes oppose transitioning these residents, added Norma Robertson-Dabrowski, director of nursing home transitions for Liberty Resources in Philadelphia.

“We go against nursing homes who think, ‘How is this person going to live in the community if they can’t speak?’” she said.

Dabrowski also urged Harkin to create a program to help disabled individuals who enter a nursing home for a minor or short-term issue such as elevated blood sugars, but then don’t have funding to continue paying for an apartment. They lose their housing “in the blink of an eye” and become long-term residents, Dabrowski said.

“You can go into a [nursing home] in twenty-four hours,” she said. “You want to get out of one, it could take twenty-four years.”

Despite these challenges, the trend toward greater integration in the community has gained momentum, Harkin and the panelists noted. For instance, technological advancements have significantly increased disabled people’s abilities to live outside institutions, they observed.

Olmstead did not call for institutional care to be eliminated, but rather for government funding to be more evenly distributed to support various types of care for disabled people, Harkin emphasized. He believes his bill would help achieve this rebalancing, and he requested that the hearing participants review the proposal and submit their recommendations.

Click here to access video of the HELP Committee hearing and a full list of participants.