All of these advances and plans were deemed at risk by 2003. State plans were systematically identifying long-standing barriers to complying with the Olmstead ruling. The state identified needs include:
- affordable and accessible housing
- assessment tools to identify people's needs
- information tools to link people with services
- data systems of monitor quality and track people at risk
- adequate staffing
- education and outreach
- availability of funded Medicaid waivers
Shortfalls in state budgets and the resulting fiscal crises meant a higher need to contain Medicaid costs, not to expand them.
A National Health Policy Forum paper in 2003 concluded that "in light of such difficult barriers and a tight fiscal environment, implementation of Olmstead might be expected to grind to a halt in virtually all states."
Tom Nerney: New Assumptions