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Alliance for Healthcare Reform Briefing:


The Olmstead Decision: Five Years Later


How has it affected health services and the civil rights of individuals with disabilities?

June 21, 2004


How has a civil rights decision come to be entangled in Medicare? Olmstead v. L.C. (1999) showed that states were in violation of the American with Disabilities Act with the practice of unjustified institutional isolation. This decision directly impacts Medicaid, which provides health and long-term services to people with disabilities. The ruling required all states to have a “comprehensive, effectively working plan for placing individuals in less restrictive settings, and a waiting list that moves at a reasonable pace not controlled by a state’s efforts to keep its institutions fully populated.”


While this ruling has created momentum, only some states have put their plans into action. A greater majority of states have plans, but no implementation of those plans. And there is still a cluster of states with no “comprehensive, effectively working plan” at all.


Medicaid is the major source of public financing for long-term care, be it in an institutional or home and community-based setting (HCBS). Even though it is less costly to provide services for a person in an HCBS environment, budget constraints require Medicaid to remain budget-neutral*, in effect reinforcing an institutional bias that enforces the status quo, resulting in many people with disabilities forced into too-restrictive environments without providing any other alternatives or options.


Financial constraints on Medicaid, lack of affordable housing for low-income people with disabilities, shortage of direct-care workers to care for people with disabilities, and political pressure of large employers, such as institutions, work to keep the status quo in place. Without significant change in culture and public attitudes, people with disabilities will continue to be misplaced in institutions. Until necessary funding can be funneled into creating community-based groups, Olmstead has the unique position of being a Civil Rights case that has tacitly been ignored.


*The initial costs to deinstutionalize the individual combined with the upkeep of the institutional facilities effectively results in an increased cost.



Eileen Elias, Deputy Director for the Office of Disability within the Office of the Secretary, Department of Health and Human Services


Michael Gottesman, Professor of Law at Georgetown University. He has argued 20 cases before the U.S. Supreme Court.


Tom Perez, Assistant Professor of Law at the University of Maryland School of Law. He was the Director of the Office for Civil Rights at the Dept of Health and Human Services from 1999-2001 and the Deputy Assistant Attorney General for Civil Rights at the Department of Justice.


Matt Salo, Director of Health and Human Services Committee at the National Governors’ Association.


Tim Westmoreland, Visiting Professor of Law and Public Policy at Georgetown University as well as counsel to the House minority staff of the Committee on Government Reform.


Bob Williams, co-director of Advanced Independence, was formerly the Deputy Assistant Secretary for Disability, Aging and Long Term Care Policy and the Commissioner of Developmental Disabilities at the Department of Health and Human Services.

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