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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
  • transportation
  • 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."

Senator Paul Wellstone and constituent
Photo courtesy Charyl Walsh-Bellville