The Olmstead decision is an interpretation of public entities’ obligations under title II of the ADA. At present, however, there are wide differences between states in the degree to which home and community-based services are provided. One reason for the uncertainty about how many may be affected is that, as the decision recognized, the appropriateness of a person’s being placed in an institution or receiving home or community- based services would depend in part on the person’s wishes and the recommendations of his or her treatment professionals. Provision of Home and Community-Based Services Varies Widely by State

The proportion of Medicaid long-term care spending devoted to home and community-based services varies widely among states. Full Implications of Olmstead for State Programs Not Yet Known

The Supreme Court’s Olmstead decision left open questions about the extent to which states could be required to restructure their current long- term care programs for people with disabilities to ensure that care is provided in the most integrated setting appropriate for each person’s circumstances. While the Supreme Court held in Olmstead that institutionalization of people with disabilities is discrimination under the ADA under certain circumstances, it also recognized that there are limits to what states can do, given available resources and the obligation to provide a range of services for people with disabilities. However, it recognized that states’ obligations to provide services are not boundless.
What GAO Found

In the Olmstead case, the Supreme Court decided that states were violating title II of the Americans with Disabilities Act of 1990 (ADA) if they provided care to disabled people in institutional settings when they could be a appropriately served in a home or community-based setting. Considerable attention has focused on the decision's implications for Medicaid, the dominant public program supporting long-term care institutional, home, and community-based services. Although Medicaid spending for home and community-based service is growing, these are largely optional benefits that states may or may not choose to offer, and states vary widely in the degree to which they cover them. The implications of the Olmstead decision--in terms of the scope and the nature of states' obligation to provide home and community-based long-term care services--are still unfolding. Although the Supreme Court ruled that providing care in institutional settings may violate the ADA, it also recognized that there are limits to what states can do, given the available resources and the obligation to provide a range of services for disabled people. The decision left many open questions for states and lower courts to resolve. State programs also may be influenced over time as dozens of lawsuits and hundreds of formal complaints seeking access to appropriate services are resolved.