Twenty-nine states have issued an Olmstead-related plan or report.

Of this total, 20 states published their plans between 2000 and 2002. Nine states--Arkansas, California, Delaware, Georgia, Kentucky, Maine, North Carolina, Oklahoma and Virginia--released their plans during 2003. Four states--Alabama, Illinois, Louisiana and West Virginia--were working on their plans during 2003 but did not release them. Several states have task forces that are working on various Olmstead-like activities but do not intend to write a plan. (See the state profiles section of this document and Table 1 in this report for details on the 29 state plans, many of which can be accessed online.)

The priorities identified in the nine plans released in 2003 mirror those in plans released earlier. As in previous years, the plans emphasize incremental development of additional community-based service capacity for people with a broad range of disabilities. The plans identify a strong community-based system as one in which consumers have a variety of options tailored to their individual needs. To be adequate, says the July 2003 Oklahoma plan, a community-based system must be consumer-driven; must provide informed choice; and must offer physical, social, political, educational and economic integration.

Creating an inclusive and broad-based planning group and planning process was important in most states. Virginia's planning process, for example, involved eight issue teams, with each team chaired by someone other than a state official. Additional individuals with expertise or interest in certain issues also were invited to take part. Most states held meetings, forums or hearings across the state as they crafted their plans. Typically, states released draft plans and modified them after a public review period.

As in previous years, 2003 state Olmstead plans include a mix of short-term and long-term recommendations. Short-term activities focused on low-cost projects that can be implemented relatively quickly. For example, several states proposed revamping assessment tools to support identification of candidates for community placement or to foster cross-disability assessment approaches. Quality assurance is another activity that can be implemented relatively quickly. North Carolina, for example, adopted continuous quality improvement strategies in its mental health, developmental disabilities and substance abuse systems. Some states identified a need for integrated data collection and analysis across agencies and service systems to facilitate integration of health services with housing, transportation, employment and other supportive services.

Several plans released in 2003 refer to state fiscal pressures as a key factor to consider when implementing plans. The plan published by the Delaware Commission on Community-Based Alternative for Persons with Disabilities did not include timelines or specific funding levels because of the realities of the state's budget problems. The California plan says a "significant challenge" to plan implementation "is the need for additional resources." Every plan noted that broad systems change is a multi-year process and that plans themselves likely will require modifications as implementation progresses. A plan is "not a static instrument," say the authors of North Carolina's plan, but "rather a guide with provisions for periodic evaluation."

These activities are essential for the state plans to remain viable. A breakdown of the follow-up and monitoring activities for the 10 states follows.

Recent federal grant and technical assistance opportunities have been, perhaps, the most promising development. The U.S. Centers for Medicare and Medicaid Services (CMS) awarded more than $158 million in new grant funds in 2001, 2002 and 2003 to the states and territories.

These awards have allowed states to implement some of their plan recommendations. States are using these grants to:

CMS and the Administration on Aging announced a new grants program in 2003 to support state efforts to develop "one-stop shop" programs at the community level. These Aging and Disability Resource Centers are intended to serve as the entry point to a state's long-term care services and supports and to help people make informed decisions about their options. In October 2003, DHHS awarded a total of almost $9.3 million in grants to 12 states to be used over a three-year period to better coordinate and/or redesign their existing systems of information, assistance and access.

CMS also has funded a National Technical Assistance Exchange for Community Living to provide training and information to states, consumers, families, and other agencies and organizations. In addition, the U.S. departments of transportation, education, housing and labor have awarded other grants to states to help develop programs, services and supports that promote affordable housing, accessible transportation, Medicaid coverage for the working disabled, and consumer information and choice.

Not only have states used their grants to further some of the goals and strategies outlined in their plans, but several of the task forces that created the plans now are the advisory groups that are assisting with their states' systems change grants. Maine's workgroup, for example, which developed its plan in 2003, is also the advisory committee for the systems change grant. North Dakota's Olmstead Commission provides oversight to the systems change grants but will likely dissolve when the grant ends.

State contacts cited the dismal fiscal situation as the most significant barrier to implementation of the Olmstead decision. Respondents noted that new state appropriations are needed to implement many of the plan recommendations, especially those related to increasing the number of waiver slots or residential settings that are available for people with disabilities. However, with stagnant revenues and increasing Medicaid expenditures, nearly all state policymakers were forced to make tough decisions to balance their budgets. New, significant appropriations in most states were off the table.

During fiscal year (FY) 2003, 37 states reported revenues below their already bleak forecasts, and the states cumulatively had to close a $17.5 billion budget gap, according to NCSL fiscal data. At the same time, Medicaid expenditures rose by approximately 9.3 percent during the previous year due to increased enrollment, service costs and utilization of services. In response, states took a variety of measures to contain costs within the Medicaid program, primarily in the areas of provider reimbursement rates and prescription drugs.

Several states reported that hiring freezes and high rates of staff turnover resulting from budget pressures have slowed progress on Olmstead implementation. The Connecticut work force, for example, was reduced by 6 percent in FY 2003; another 9 percent of the work force took early retirement. A state employee hiring freeze in effect in New Hampshire is affecting Olmstead-related activities.

Pending and settled lawsuits generally involve people with developmental disabilities, and more than three-fourths of Medicaid funding goes toward services for people with developmental disabilities. Thus, it came as no surprise that 21 states and the District of Columbia described efforts to expand home and community-based services for people with developmental disabilities.

However, states showed new interest in the areas of mental health, aging, work force and housing.

It is difficult, if not impossible, to accurately and comprehensively report on Olmstead-related appropriations across all state agencies and disability populations. Most states could report on positive Olmstead efforts and also report on programmatic cuts.

Olmstead implementation was mixed even within states. Publicly funded home and community-based services span a plethora of state agencies and serve diverse populations-senior citizens, younger people with disabilities, people with developmental disabilities, and people with mental illness. Thus, some long-term care programs and services fared better than others as states faced difficult fiscal situations.

As mentioned above, Connecticut reduced its state work force, but it increased assisted living options and provided opportunities for nursing home transitions. Georgia, where the Olmstead lawsuit originated, reduced state agency budgets by 2.5 percent in FY 2004 and by another 5 percent in FY 2005, but it allocated $9.6 million in FY 2004 for Olmstead initiatives, which included moving people from institutions into the community. Georgia also is restructuring its mental health and developmental disability systems and is implementing a new system for intake, assessment and support coordination. Mississippi is serving more people in its Medicaid waiver programs, but the waiver waiting lists are growing. During the past five years, the state has experienced a greater than 200 percent growth in its waiver programs.