ON THE HORIZON
Community-based long-term care services and state efforts to make them more available have taken on new urgency since the 1999 U.S. Supreme Court decision in Olmstead vs. L.C. Under the Americans with Disabilities Act (ADA), states must serve persons with disabilities in the most integrated setting appropriate to their needs. The Court held that states discriminate against the disabled when individuals who could be served in the community are in institutions. In essence, it held that no one should have to live in an institution if they can live in the community if appropriate care and support are provided. Although the Olmstead case involved two people with mental disabilities, the scope of the ADA extends to those with other disabilities, including the elderly and people with physical disabilities.
While growth in community-based long-term care services has been seen in the past as a desirable option, it will now become a necessity. Each state's community-based long-term care services will be held to a new standard: Is each disabled person getting care in the most integrated setting? The Court directs states to provide community-based services to a person who would otherwise be in an institution when such a placement is appropriate, when the person affected does not oppose such treatment and when the placement can be reasonably accommodated. Such accommodations must be made unless they fundamentally alter the nature of the service.
The Court ruling suggests that a state can meet its obligation by 1) developing "comprehensive, effectively working plans" to serve persons with disabilities in the community and 2) assuring that waiting lists for community services move at a reasonable pace and are not controlled by any interest in keeping institutions fully populated.
An important starting point for a plan is an assessment process for persons with disabilities. Through such a process, states can determine both how many disabled people currently in institutions are eligible for services in community-based settings and how many now in the community are potentially at risk of an unnecessarily restrictive placement. Building on the assessment activity, they can develop a working plan built around the specific needs of people with disabilities that will move them into the community at a reasonable pace.
As legislators participate in plan development, they will want to consider what changes are needed in the state's service system to provide new types of services efficiently and in accordance with the choices of persons with disabilities. They will want to identify ways to involve persons with disabilities in the plan development process.
How to pay for services will be a critical issue. While states are likely to face resource constraints in implementing their plans, most expect their Medicaid programs-especially home and community-based services waivers-to be the primary vehicle for providing planned services. In some cases, quality assurance mechanisms, information systems, and administrative oversight and review mechanisms designed for a small number of waiver participants may need modification to serve more people.
The Olmstead case suggests that states, which uniformly have been moving toward expansion of community-based services, will need to find ways to make more of these services available more quickly, and to many more people. Building community-based long-term care services has never been easy. Making such services the placement of choice for most persons with disabilities in a reasonable period of time will intensify the challenges and will require sustained attention from state legislators and other policymakers.
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