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ICF Advocates for Choice

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About ICF Advocates for Choice

We are a national grassroots organization of parents, family members, friends and concerned citizens who advocate and educate to protect, expand, and promote the professional, therapeutic level of ICF (Intermediate Care Facility) Long term Supports and Services in the Disability Service System for the severely and profoundly developmentally disabled. We are ICF Advocates for Choice, Choice without Boundaries and we boldly proclaim the absolute necessity of the ICF level of care required for the health and safety of our medically fragile with IDD and severely behaviorally challenged autistic adult loved ones. While thousands of other special interests and professional lobbyists advocate for the one size-fits-all "Community" only, we are the only national organization that specializes and devotes our time, energy and resources in advocating for those who need the ICF level of care. The "Community" has plenty of supporters, we are here to help the most medically fragile with IDD, the most profoundly autistic and their suffering, beleaguered families, who need a voice more than anyone. 

The following public comment was submitted to the Interagency Autism Coordinating Committee in advance of its July 21-22, 2021 meeting. It is public record and reprinted here:


Stephen Wallace, J.D. and Debra Wallace

Red Rock, Texas

Father/Co-guardian of [name redacted], Austin State Supported Living Center ICF Advocates for Choice

Parents and Allies of Remarkable Texans

IACC Workshop- Keeping the Olmstead Promise

My name is Stephen Wallace, and I am first and foremost the father and co-guardian of a forty year old son with severe autism. As I thank you for the opportunity to address this committee, I want to note that while I have been a father dealing with autism for nearly four decades, I have actually been confronting the issue of autism for at least a decade longer. I volunteered and later continued to work as a teacher and daily living trainer for autistic children in the late 60s and early 70s. In a cosmic case of irony, in 1980, our son [name redacted] was born. By 1983, he had received multiple diagnoses and confirmations as having a pervasive developmental disorder with autistic tendencies.

Our son, the fourth of five children, remained home and a vital part of our family for the first 18 years of his life. But as the years progressed, he became more aggressive and self-injurious. We fought for inclusive programs with behavioral interventions at school, and even obtained the highly sought after and coveted in-home waiver service, which provided the latest and best services available. By 1998, all of the providers the state could offer refused to work with our son, and his school had long given up being able to deal with the increase in his aggression. After multiple near death experiences and almost regularly scheduled visits to the emergency room, we realized we had no other option than to place him in a highly structured residential facility with 24 hour a day protection and supervision.

The day we placed [name redacted] remains the darkest day of our lives to date, but that previously unthinkable option was the only one left that offered the hope of keeping him alive.

When the time came, we had to fight to achieve the very thing we had most feared. The movement toward community placement had already begun in earnest, and congregate care was already seen as an outdated concept.

“Those on the severe end of the spectrum who demonstrate aggressive or self-injurious tendencies continue to grow in numbers.... The simple fact is, thousands upon thousands of families will shortly be confronted by the need for more intensive care and treatment for their loved ones with autism. ”

Many of those who parent, protect, or love someone with autism will unfortunately face that same dilemma that confronted our family. Those on the severe end of the spectrum who demonstrate aggressive or self-injurious tendencies continue to grow in numbers which exceed effective service provision available in the home or community. The simple fact is, thousands upon thousands of families will shortly be confronted by the need for more intensive care and treatment for their loved ones with autism. Growth in effective residential services has been stymied by a lack of resources, and compounded by the growth and acceptance of a mythical notion known widely as the “Olmstead Mandate”. The myth grows from a 1999 Supreme Court decision rendered in Olmstead v. L.C. (527 U.S. 581), which held that unjustified segregation for persons with disabilities is a violation of the Americans with Disabilities Act, but stated the ruling was conditioned upon three factors which must be considered in each case; the treatment team responsible for the care of that individual agreed that appropriate services could be offered in a less restrictive environment, that the individual receiving services did not object to being relocated to a less restrictive environment, and that the state could offer those same services in a less restrictive setting without undue hardship. The very conditional and specific holding has, over the last 22 years, been transformed by community advocates, and agencies on the federal and state level, into a mythical tool to indiscriminately close needed residential facilities, or at least demonize their very existence.

The narrative created and enhanced by this myth is now leading to, for many of us who rely on the intensive care offered by congregate facilities, a dystopian future where our loved ones have no refuge. Currently, thousands of individuals exist in our communities, languishing with unmet needs and protections, isolated in plain sight of a society that has little understanding or tolerance of the needs of the profoundly or severely afflicted. Even more will follow as increasing numbers age out of the education system and are thrown into the void of non-existent services for adults with autism.

“Currently, thousands of individuals exist in our communities, languishing with unmet needs and protections.... Even more will follow as increasing numbers age out of the education system and are thrown into the void of non-existent services for adults with autism.”

It is time that the dangerous narrative of independence or bust be revealed for what it is; a notion fitting some, but leaving so many more without even the most basic services to keep them out of harm's way. A realistic but compassionate view of the difficult futures faced by those with severe autism, must be adhered to, and it must contain the realization that some of our numbers will never develop the skills or capacity to protect themselves from abuse, exploitation, hunger, neglect or death. If not, then the current trend of community for all will result in an abandonment of our obligation to care for those who cannot care for themselves and end with the most profoundly impacted individuals being lost as collateral damage to the movement. True advocates for all of the disabled, and agency officials who create and administrate must awaken to the coming tide, if the most needy on the autism spectrum are to thrive and survive. Now is the time for those who can mold the future to realize that more intensive services such as ICF congregate care facilities are not only still relevant , but will be even more essential in the future. The myth of the Olmstead Mandate must be counteracted by an intelligent and responsible provision of services for a population which will not cease to be just because we deny their existence.

See What People Are Saying

"If not, then the current trend of community for all will result in an abandonment of our obligation to care for those who cannot care for themselves and end with the most profoundly impacted individuals being lost as collateral damage to the movement."


"Now is the time for those who can mold the future to realize that more intensive services such as ICF congregate care facilities are not only still relevant , but will be even more essential in the future. The myth of the Olmstead Mandate must be counteracted by an intelligent and responsible provision of services for a population which will not cease to be just because we deny their existence."

When It Comes to People Like My Daughter, One Size Does Not Fit All - New York Times By David Axelrod - July 4, 2021

My daughter, Lauren, turned 40 last month. She is happy and healthy. And that is nothing short of a miracle.

From the moment my wife, Susan, found Lauren blue and limp in her crib at the age of 7 months — the consequence, we later would learn, of epileptic seizures she suffered in the night — Lauren’s life has been a struggle.


These brutal seizures would continue, poorly controlled, for the next 19 years, roiling her developing brain and necessitating an ever-shifting regimen of medications with punishing side-effects, of surgeries and hospitalizations. More than once, we feared we would lose her.

Lauren’s doctors finally found a cocktail of medications that would work to subdue the seizures, but the battering her brain took from the ordeal left her with significant developmental deficits.


We moved our family from one town to another in search of special education programs that would include her, with adaptations, in regular classrooms. But as the years went by and her classmates matured emotionally and intellectually, the gap between Lauren and her peers became a chasm. The girls and boys around her were growing into young women and men, with all that entails, while Lauren was still in many ways a child, poignantly struggling to find her place.


Lauren’s seizures had been terrifying and painful. But her loneliness was absolutely heartbreaking. She longed for friendships and, whenever she got the chance, gravitated to others with similar challenges and shared experiences. Lauren didn’t need words, which were often hard for her to find, to communicate loud and clear to us what mattered most to her.

When high school ended, we faced a cliff familiar to many parents of children like Lauren. In Illinois, as in most states, jobs and services for adults with disabilities are woefully inadequate. We struggled to find programs and opportunities for the relationships that Lauren craved.

We agonized over whether this would be her future, sitting at home, waiting for activities, without an independent life of her own. We anguished over what would happen when we were gone.


But 19 years ago, that all changed.


Lauren moved to Misericordia, a remarkable community for people with intellectual disabilities near us on Chicago’s North Side. For the first time, her days were rife with activities and her life was filled with friends.


No, it’s not the life we envisioned for Lauren the day she was born, a seemingly healthy, bright-eyed little girl. But looking back at the obstacles she’s faced, she’s thriving in ways that once seemed impossible.


Lauren shares an apartment with two other women in a bustling dormlike setting on a pleasant, leafy campus. She and her friends walk to nearby shops and restaurants. She has vocational activities and jobs on campus and off, which have given her a sense of worth and responsibility. She sings and signs in a choir, takes art and cooking classes, and hits the fitness center or pool every day.


While she has the care and supervision she continues to need — and always will — she also is more independent than we ever could have hoped.

Most of all, she is happy. Genuinely happy.


I wish that were the end of the story.


But today, Lauren faces another battle, not with epilepsy or the toll it’s taken, but with policy changes that could deny her and others with intellectual disabilities the life they choose in concert with their families and loved ones.


The issue is federal Medicaid funding to states, which helps underwrite residential facilities for people with intellectual disabilities, and the conviction of some advocates and policymakers that larger settings like Misericordia should be discouraged.


The debate is rooted in an ugly history. For generations, Americans with intellectual disabilities were too often sent to large institutions where they were warehoused, abused and deprived of the opportunity to live their fullest possible lives.


I am profoundly grateful for the disability rights movement that has waged a decades-long battle to shutter such institutions, many of which were run by the states, and to win for people with intellectual disabilities the right to live in small apartments and homes with services in residential neighborhoods.


But now the ideal has hardened into dogma: All larger communities are bad. All small, neighborhood-based group homes are good.


Of course, neither of these things is true, and the rigidity of that thinking denies the simple truths that there are good and bad places, large and small, and people with disabilities are not all the same. Like anyone else, they have different personalities, capacities and preferences.


Some may thrive in small homes or apartments in residential neighborhoods. Lauren has that option through Misericordia but prefers the socialization of her dormlike setting and the constant stimulation of campus life.


But rather than ensuring a full range of high-quality residential options for people with disabilities to fit their individual needs and circumstances, the prevailing view of many policymakers is to compel a one-size-fits-all answer.


What is painful is that these changes are being promoted by good people, trying to do the right thing. Many are my friends and former colleagues.

We saw this play out through the American Rescue Plan Act, enacted in March, which explicitly provided disproportionate aid to smaller community-based group homes and in-home care settings over larger settings like Lauren’s home in Misericordia.


The Rescue Act included emergency funding to increase pay for direct-care workers in home and neighborhood-based settings. But it omitted equally deserving women and men who work in larger settings and devotedly support Lauren and others. (Misericordia received some of this emergency funding but only for its neighborhood-based group homes, not the main campus.)


Now a proposal by Democratic leaders in Congress — the Better Care Better Jobs Act — would vastly expand federal funding for home and community-based services for the elderly and people with disabilities, which I strongly support. It is badly needed and long overdue.


But as currently written, the plan also would make the funding disparity based on size and type of care permanent, which is wrong. It is a formula that disadvantages larger settings and gives states further incentive to shift away from them, even if they are doing extraordinary work.


Instead of judging by size, isn’t the right path to fully fund an array of high-quality options and afford people like Lauren the dignity of choice and the happiness they deserve?


COFAR and AFSCME warn that President Biden’s HCBS expansion plan could harm ICFs

June 21, 2021 By David Kassel

COFAR has joined with AFSCME Council 93, a key Massachusetts state employee union, in warning that President Biden’s proposed $400 billion expansion of home and community-based services for people with disabilities and the elderly could pose a threat to the future of state-run services.

In a jointly written letter to U.S. Senator Elizabeth Warren, COFAR President Thomas J. Frain and AFSCME Council 93 Executive Director Mark Bernard expressed overall support for Biden’s proposed expansion of access to affordable home and community-based services (HCBS) for people with I/DD and the elderly.

But the letter noted that Biden’s plan fails to similarly propose any additional funding for state-run Intermediate Care Facilities (ICFs) for persons with I/DD and complex medical needs.

Expanding only HCBS, the letter said, would pose “a serious threat to the future of critically important ICF-level care in this country…(and would) interfere with the ability of individuals, particularly those with severe forms of I/DD, to access the residential settings and programs that meet their needs.”

Biden’s $400 billion HCBS expansion plan is part of his $2 trillion American Jobs Plan, a proposal to Congress to rebuild the American economy and the nation’s infrastructure.

The two remaining state-run ICFs in Massachusetts are the Wrentham Developmental Center and the Hogan Regional Center in Danvers.

Steering increased funding only toward community care would create a strong incentive for Massachusetts to close the Wrentham and Hogan facilities, the AFSCME-COFAR letter stated.

In addition to stripping the DDS system of a badly-needed component of the continuum of care for the developmentally disabled, the closure of the ICFs would jeopardize the jobs of approximately 1,400 union workers represented by AFSCME alone.

ICFs provide needed choice

The joint letter noted that choice in care is only meaningful if individuals are given access to the services that they need and prefer. As the United States Supreme Court held in the 1999 Olmstead v. L.C. case, there must be a recognition that, on a case-by-case basis, that setting might be in an ICF.

But the Massachusetts DDS does not routinely inform either individuals or their families who are waiting for residential placements even of the existence of either ICFs or state-operated group homes. The only “choices” routinely offered are corporate provider-run group homes or, in some cases, shared living arrangements. As such, families do not have a real choice along a full continuum of care.

The number of residents at the Wrentham and Hogan ICFs and in state-operated group homes has been declining in Massachusetts for several years. State funding for state-operated services has also been flat or has declined over the past decade.

In contrast, funding has skyrocketed for corporate, provider-run group homes. Successive administrations have long engaged in a race to privatize DDS services.

Calling for parity

The joint letter noted that In Fiscal Year 2019, Medicaid spending nationwide was $76 billion for HCBS and $9 billion for ICFs. Out of total Medicaid spending nationwide for long-term supports and services, 59% was spent on HCBS and 7% on ICFs.

If the Massachusetts Legislature concurs with Governor Baker’s proposed funding for DDS for Fiscal Year 2022, the corporate provider line item will be funded at more than $1.4 billion. That would represent a 91% increase over the funding appropriated for the same line item a decade previously, in Fiscal 2012.

In contrast, funding for state-operated group homes and the two remaining ICFs has been on a relatively flat or downward trajectory respectively.

When adjusted for inflation, the governor’s Fiscal 2022 budget would cut funding for state-operated group homes by somewhat less than 1% from the current fiscal year. The Wrentham and Hogan centers would similarly see their funding cut in Fiscal 2022 by a total of $2.1 million. Since Fiscal 2012, funding for the developmental center line item will have been cut by 32%.

The joint letter stated that the ongoing under-funding of state-run DDS programs has resulted in the increasing privatization of those programs and services.

Massachusetts State Auditor Suzanne Bump’s office reported in 2019 that while the resulting boost in state funding for privatized care produced surplus revenues for corporate providers, those additional revenues led to only minimal increases in wages for direct-care workers.

Disparity in care

The joint letter stated that In 1993, then U.S. District Court Judge Joseph L. Tauro ordered that ICFs in Massachusetts not be closed unless it was certified that each resident would receive equal or better care elsewhere. Judge Tauro was bringing an end to a landmark consent decree (Ricci v. Okin), which had resulted in major upgrades in care and services in the DDS system.

As the years went on, however, the promise of equal or better care in the community was not realized. Deinstitutionalization has turned out to be fraught with problems for people with I/DD just as it has for people with mental illness.


In testimony in 2018 to the state Legislature’s Children, Families, and Persons with Disabilities Committee, Nancy Alterio, executive director of the Massachusetts Disabled Persons Protection Commission (DPPC), stated that abuse and neglect in the DDS system had increased 30 percent in the previous five years, and had reached epidemic proportions.

Yet many advocates for corporate providers, such as the Arc of Massachusetts, have pushed for decades for complete deinstitutionalization and for additional privatization of services for people with I/DD. They have been joined by administrations at the state and national levels, which have continually made state-run care and services targets for closure and outsourcing to contracted providers.


Since 2009, the U.S. Justice Department has filed, joined, or participated in lawsuits around the country to close ICFs regardless of whether the residents or their families or guardians wanted to close the facilities they were living in or not.


Olmstead did not call for the closure of ICFs

The late U.S. Supreme Court Justice Ruth Bader Ginsburg wrote the majority opinion in the Olmstead case (referred to above). The decision has continued to be mischaracterized as advocating or requiring the end of institutional care. It didn’t. Justice Ginsburg wrote a balanced decision that “supports both the right to an inclusive environment and the right to institutional care, based on the need and desires of the individual.”


The incestuous nature of the privatized system

The closures of ICFs around the country and the rise of the privatized system of care have provided financial windfalls for politically connected corporate contractors. Their executives have garnered large increases in their personal compensation, but have frequently neglected to pass through the higher levels of state funding to direct-care workers. That is one of the reasons for the epidemic of abuse and neglect in the corporate provider-based system of care.

In 2015, COFAR calculated that more than 600 executives employed by corporate human service providers in Massachusetts received some $100 million per year in salaries and other compensation. By COFAR’s calculations, state taxpayers were on the hook each year for up to $85 million of that total compensation.


What we are asking for

The COFAR-AFSCME letter asked for Senator Warren’s support in achieving the following goals:

Parity in public-sector funding for ICFs and other state-run services with funding for privatized services. The letter suggested that an increase in the federal Medicaid match for HCBS should be matched by an increase in matching funding for ICFs. For example, a 10-percentage point increase in the federal match (FMAP) for ICFs would be roughly $1 billion nationwide.

Ensuring a dedicated funding stream for state-operated group homes for individuals with I/DD.

The Parents Perspective

Steve Wallace on his 34 year old, severely autistic son Justin

Austin State Supported Living Center

Susan Jennings on the Housing Needs for her severely autistic 29 year old son, Joey


It's Time for Accountability for the DD Act Programs - Protection & Advocacy Transparency Amendment

The Developmental Disabilities and Bill of Rights Act of 1975 (DD Act), which is administered by Administration for Community Living (ACL), created four programs  -DD Act programs include: (1) Protection and Advocacy System for Persons with Developmental Disabilities (PADD), (2) State Councils on Developmental Disabilities (CDD), (3) University Centers for Excellence in Developmental Disabilities (UCEDD) and (4) Projects of National Significance (PNS). DD Act programs operate in every state.  The DD Act and its programs were last reauthorized for a period of seven (7) years in 2000 (Public Law 106-402- October 30, 2000).


The Administration for Community Living (ACL) uses its resources and allows the DD Act programs to undermine and eliminate the Medicaid intermediate care program (ICF) for persons with intellectual and developmental disabilities (ICF/I-DD).   Our loved ones, who are medically complex and behaviorally challenged require intensive supports and 24-hour nursing care and close supervision, but ACL – an agency of Health & Human Services—is effectively working to remove vitally needed health care from our medically and neurologically complex individuals.

ACL permits the DD Act Protection and Advocacy Systems for Persons with Developmental Disabilities (PADD) to initiate class action lawsuits sweeping thousands of at-risk persons into litigation that is directly counter to their health, safety and welfare. ACL approves such “systemic litigation” as an “intervention strategy.” It is wrong to use our own tax dollars to force innocent individuals into federal litigation that seeks to undermine their own health care and residential supports against the will of their loving families and guardians.  


The ACL and its programs work to eliminate the model of healthcare and residential supports which families know is vitally required for our at-risk loved ones and they ignore key provisions in the DD Act which support the role of families as primary decision-makers for services and supports for their family members with disabilities. 

The ACL ignores the following key provision:

(c) POLICY

It is the policy of the United States that all programs, projects, and activities receiving assistance under this title shall be carried out in a manner consistent with the principles that

. . .

(3) individuals with developmental disabilities and their families are the primary decision makers regarding the services and supports such individuals and their families receive, including regarding choosing where the individuals live from available options, and play decision-making roles in policies and programs that affect the lives of such individuals and their families;

Title I, Sec.101

Public Law 106-402 Developmental Disabilities Assistance and Bill of Rights Act of 2000.

Protection & Advocacy Transparency Amendment

At long last, a courageous Ohio Senator, concerned by reports from families that Disability Rights Ohio was speaking to family members without the guardians present has  added an amendment (SC 3841 - Omnibus Oversight Language) to the state budget that calls for oversight of DRO.  This bill creates an oversight committee on DRO actions.


"Sec. 5123.603. (A) Every two years, the president of the

6 senate and speaker of the house of representative shall

7 establish a joint committee to examine the activities of the

8 state's protection and advocacy system and client assistance

9 program.




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