Olmstead and Health Policy: The State Context

Presenter Name: Donna Folkemer

Institution: National Conference of State Legislatures, Washington, DC


In June 1999, the Supreme Court ruled in L.C. & E.W. vs. Olmstead that it is a violation of the Americans with Disabilities Act for states to discriminate against people with disabilities by providing services in institutions when the individual could be served more appropriately in a community-based setting. States are required to provide community-based services for people with disabilities if treatment professionals determine that it is appropriate, the affected individuals do not object to such placement, and the state has the available resources to provide community-based services. The Court suggests that a state could establish compliance with the Americans with Disabilities Act if it has 1) a comprehensive, effective working plan for placing qualified people in less restrictive settings, and 2) a waiting list for community-based services that ensures people can receive services and be moved off the list at a reasonable pace.

To better understand the effects of the Olmstead ruling, the National Conference of State Legislatures (NCSL) conducted a 50-state survey. Results from that first survey provide an overview of the choices states are making as they act on their obligations under the Olmstead decision.


The study categorized overall state activities around Olmstead, according to their scope and purpose; provided detailed descriptive analyses of Olmstead plans, including analyses of priorities, action steps, timetables, budgetary and legislative strategies, and other relevant factors; and identified and described targeted efforts planned on behalf of people with disabilities.


NCSL surveyed each state's main contact(s) for Olmstead activities during 2000, 2001, and 2002. During the telephone interviews, survey respondents provided information on the following topics: Olmstead activities, consumer involvement, lawsuits, implementation deadlines, major recommendations and priorities, strategies for implementing the recommendations, costs and funding. These state summaries represent only brief sketches of activities in each state.


  1. Forty-two states plus the District of Columbia have task forces, commissions or state agency work groups to assess current long-term care systems; many are developing plans. Eight states-Kansas, Michigan, Minnesota, Nebraska, Oregon, Rhode Island, South Dakota, and Tennessee-do not.
  2. Twenty-one states have issued Olmstead plans or significant papers, and twelve states expect to release plans in 2003.
  3. Several states have task forces that are working on Olmstead-related activities but are not intending to issue comprehensive plans.
  4. Most commissions are broad-based and have cross-disability policies in that their scope of work includes all people with disabilities and several of them publish their activities on the Internet.
  5. To shift more resources into community-based settings, state commissions have issued numerous recommendations that address ten major issues-transitions from institutions to communities, housing, retaining direct care workers, information and assessments, funding following individuals, reducing waiting lists, employment opportunities, data collection, transportation, and quality care.
  6. State legislation enacted in 2002 creates Olmstead task forces, sets up consumer-directed care programs, and strengthens information, referral and assessment services.
  7. State budget shortfalls and declining state revenues have delayed plan implementation, but states are implementing less costly recommendations, conducting pilot projects and using federal grant funds to enhance systems change.


Decreasing revenues and rising Medicaid costs caused tight budgets in most states in FY 2001 and FY 2002 and continued concern in FY 2003. The November 2002 election of new state legislators and governors marks a change in leadership in many of the states. The effect of these developments on long-term care reforms in the states is uncertain. A number of states are considering cost-containment options, many of which affect long-term care programs and services.

However, several state plans are works in progress for the long run. These plans will evolve in response to funding, stakeholder input, agency-related initiatives, and continued growth and demand for community services and supports for people with disabilities.



  1. Olmstead plans provide a basis for evaluating the success of states in meeting their objectives for services to persons with disabilities.


  1. Olmstead plans provide a basis for understanding the goals of states in community-based care.
  2. Olmstead plans provide a basis for identifying potential legislative and regulatory strategies of states related to community based care.


  1. Olmstead plans provide a basis for assessing the capabilities and training needs of clinical and other personnel responding to the needs of persons with disabilities.

What implications do your research or training project findings have for changes in concepts of health and disability?

The ADA, as interpreted by Olmstead, guarantees persons with disabilities the right to receive care in the most integrated setting possible. State plans identify the conceptual underpinnings of state approaches to Olmstead implementation.