Strategies to Improve Access to Medicaid Home- and Community-Based Services Senate Questions and National Council on Disability Responses for the Record

May 3, 2004

From Chairman Grassley:

1. The National Council on Disability was established about 25 years ago in 1978. In between now and then, the disability community has won two significant victories: the passage of the Americans with Disabilities Act in 1990, and the Supreme Court's Olmstead decision in 1999. Would you comment on the changing role of the National Council on Disability over time?

Since the National Council on Disability (NCD) was established on November 6, 1978, there have been a number of critical victories, to which NCD has directly contributed that include, but are not limited to, the following:

• Passage of Public Law 97-35, the Social Security Act, Section 2176 of P.L. 97-35 established section 1915(c)} of the Act which established the Medicaid Home- and Community-Based Services (HCBS) Waiver program;
• Passage of Public Law 97-248, the 1982 Tax Equity and Fiscal Responsibility Act which permitted states to cover home care services for certain children with disabilities under Medicaid (Katie Beckett waiver);
• Passage of Public Law 99-506, the Rehabilitation Act Amendments of 1986 which broadened the purposes of the Act which required consumer control of Boards in Centers for Independent Living, and required states to establish State Independent Living Councils;
• Passage of Public Law 101-336, the Americans with Disabilities Act (ADA) which created a national mandate for the elimination of discrimination against individuals with disabilities in employment, public services, and public accommodation and services operated by private entities;
• Passage of the Public Law 104-204, the Mental Health Parity Act of 1996 which prohibited certain insurance companies from lifetime cap differences between mental health and medical treatment allowances;
• Passage of Public Law 106-170, the Ticket to Work and Work Incentives Improvement Act of 1999 which was established to provide SSI and SSDI beneficiaries with a ticket for vocational rehabilitation services, employment services and other support services from an employment network of their choice; and
• The 1999 Supreme Court Olmstead decision which interpreted Title II of the ADA as a mandate for public entities to provide services to persons with disabilities in the most integrated setting appropriate to their circumstances.

Paralleling what has occurred in our nation with the emergence of the disability rights and independent living movements, over the past 25 years, NCD has fulfilled its statutory mandate to be a voice within the Federal Government for policies, programs, practices, and procedures that

• guarantee equal opportunity for all individuals with disabilities, regardless of the nature or severity of the disability; and
• empower individuals with disabilities to achieve economic self-sufficiency, independent living, and inclusion and integration into all aspects of society.

Over the past 25 years, NCD has been intrinsically involved in achieving progress for people with disabilities and consistently fulfilled its unique role as the only federal agency charged with addressing, analyzing, and making recommendation on issues of public policy that affect people with disabilities regardless of age, disability type, perceived employment potential, economic need, functional ability, veteran status, or other individual circumstance.

Notwithstanding the many great victories listed above, as well as the wealth of information and advice NCD has provided to the Federal Government since 1978, NCD firmly believes that much more work needs to be done to ensure that people with disabilities are able to live real lives. Based on its reports (http://www.ncd.gov/newsroom/publications/2004/publications.htm), NCD continues its work to ensure that:

• existing laws are enforced;
• outreach and awareness campaigns are launched to educate the public about the human and societal benefits of achieving independence for people with disabilities and the important role that civil rights and community-based supports play in promoting independence;
• incentives for the inclusion of people with disabilities in all aspects of society are further developed and implemented;
• principles of universal design are applied in creating more livable communities for people with disabilities;
• systems, services, and supports for people with disabilities are further developed as a part of the mainstream of community life; and
• accurate data about people with disabilities are regularly collected, analyzed, reported, and used to strengthen laws and programs on behalf of all Americans.

Follow-up:
Would you describe if and how the health care delivery system is changing to accommodate individuals with disabilities in response to these victories (ADA and Olmstead)?

Under the ADA, it is generally believed that there is better physical access to health facilities in the United States. The Olmstead decision, however, was not about the health care delivery system, per se. In 1999, the United States Supreme Court held in Olmstead v. L.C., 527 U.S. 581 that, under the Americans with Disabilities Act (ADA), undue institutionalization qualifies as discrimination by reason of disability and that a person with a mental disability is "qualified" for community living when the state's treatment professionals have determined that community placement is appropriate, the transfer from institutional care to a less restrictive setting is not opposed by the individual, and the placement can be reasonably accommodated, taking into account the resources available to the state and the needs of others with mental disabilities.

The plaintiffs in Olmstead were the 'victims' of the same type of institutional medical/health care bias in the Medicaid system that the Senate Finance Committee is trying to address by virtue of its April 7, 2004 hearing. It is not the "health care delivery system" that lies at the heart of this hearing, but rather, it is the long-term services and supports system that promotes community integration, independence, and individual choice that is changing and in need of more improvement such as that proposed by MiCASSA and the Money Follows the Individual Rebalancing Demonstration.

2. In your written testimony, you mention that the need for viable alternatives to institutional care requires serious attention and concern due at least in part to the aging of the nation's population. What policies described in the New Freedom Initiative and elsewhere will help ensure that the availability of community-based or in-home services meets the demand into the near future?

The costs of providing long-term services and supports for both the growing population of senior citizens (many of whom will be people with disabilities) and persons with disabilities under the age of 65 will continue to grow rapidly. Demographics alone, including the projected doubling between 1980 and 2030 of the number of Americans over 65, make this inevitable, even without regard to changes in per capita costs. Few people would choose institutional care over their own homes and neighborhoods, if allowed to make that choice with dignity, autonomy and comfort. A February 2002 HHS study revealed that as many as 90 percent of the nation's nursing homes may face staff shortages that compromise adequate resident care. For all these reasons, the variety of initiatives summarized under the Olmstead rubric can be said to carry with them the destiny of a generation.

Creation of a paradigm to meet these new needs and fulfillment of the Olmstead promise on behalf of institutionalized or at-risk Americans with disabilities (seniors and younger persons alike) presents structural, resource allocation, public-private partnership, coordination and federalism issues of unprecedented and sometimes baffling complexity. NCD has repeatedly praised the commitment of the Bush Administration through the NFI to the values of ADA, as embodied in the Supreme Court's 1999 Olmstead v. L.C. decision. As indicated by President Bush's 2001 Executive Order and the subsequent coordinated planning, the Administration recognizes that new levels of interagency cooperation and high-level oversight will be necessary for the success of Olmstead in ensuring that Americans with disabilities can live (as they have already long been legally entitled to learn and to work) in the most integrated settings possible. New concerns have arisen over the sustainability of progress, as the Olmstead initiative confronts major new challenges while still endeavoring to surmount the old ones.

Federal Coordination

As the initial participation of nine major federal agencies in the comprehensive planning process under the President's June 2001 community-based living executive order attests, few policy initiatives involve so many agencies and programs as Olmstead. In order to marshal the community resources necessary for the success of Olmstead (that is, to enable people to leave institutions and to prevent at-risk citizens from entering them), the resources, procedures and priorities of over a dozen traditionally separate and self-referencing service systems, funding streams and statutory jurisdictions must be coordinated. At a minimum these include, at the federal level, Medicaid (both regular and waiver programs), transportation, housing, assistive technology, attendant services, food and nutrition programs, Older Americans Act, Social Security Administration (SSA), community development block grants, independent living and veterans benefits, along with private insurance and pensions and state and local programs with their rules and discretionary interpretations of federal provisions. Even the tax system is implicated in the success of Olmstead, insofar as the costs of many categories of home care and assisted living services do not qualify for deductibility, whereas equivalent costs, if encompassed in the fees charged by nursing homes, can lower the middle class family's or individual's tax obligation.

The nature of the coordination required to make Olmstead and the NFI work may well exceed the administrative and planning resources currently available for the purpose. Recent experience in other spheres of policy has demonstrated the enormous difficulty of, and the entrenched institutional and jurisdictional barriers to, achieving seamless, coordinated interagency action, based on shared goals, methods, information resources, timeframes and standards of accountability, among divergent federal agencies, each with its own budget, institutional culture and chain of command. The key problem remains that no one agency is capable of making or carrying out plans in ways and according to timeframes that fully anticipate and reflect the related plans and activities of all the other key participants.

Until or unless coordinating structures such as the Interagency Committee on Community Living (ICCL) can be constituted with the resources and authority to accomplish or compel coordinated planning, the best planning efforts of any one agency may be all too easily negated by the varying priorities or differing time horizons of another, or even of another entity within the same department or under the same management.

These coordination problems also emerge in the budgeting process. Olmstead implementation is not a budget line or cost center in its own right. Thus, when the budgets for the various programs, statutory responsibilities and functions making up the work of each agency are determined, impact on Olmstead is hardly the key variable determining whether or how much programs will be cut. While one agency may develop its budget recommendations and requests to the OMB and Congress with Olmstead in mind, others may not.

As a result, NCD recommends that the Federal Government begin developing cross-agency program scoring methods and unified budgeting models that will link the relevant activities and budget requests of various agencies so as to allow the impact of budget proposals on multi-agency policy initiatives such as Olmstead to be tracked and reported and to allow effective budgeting for multi-agency initiatives. In connection with coordination, NCD commends the administration for two major NFI-related initiatives during 2002: establishment within HHS of the Office of Disability and creation of two new Independence Plus waiver programs within Medicaid. The Office of Disability should contribute considerably to coordination within HHS and the agencies it supervises and may develop linkages with similar coordinating offices in other departments that will add further coherence to the federal effort. The new waiver programs reflect important early steps toward infusing consumer-directed community-based services by giving states more flexibility to direct funds in accordance with beneficiary choices.

But as encouraging and innovative as these measures are, they may in the end serve as much to highlight the seemingly intractable problems of coordination as they do to resolve them. For in the absence of interconnected and timely actions by other departments, the effects of what any one agency does in the Olmstead context may be considerably diminished. It does little good, for example, to give an individual the option to use Medicaid waiver funds to provide home-based services rather than going to a nursing home (to allow for the money to follow the person) if no accessible housing is available in the community that can meet the individual's needs, or if no accessible or affordable transportation is available between the accessible housing and other locations in the community where the individual needs or wishes to go. Without transportation, the isolation of one's own home can all too easily become as crushing as that of an institution.

Additional Federal Initiatives - Public-Private Partnerships

Any full-fledged effort to make the promise of Olmstead and Title II of ADA a reality depends upon both private sector and public resources. So far as the resources of individuals and families are concerned, we have already noted that, even for people of sufficiently modest means to qualify for Medicaid (particularly where spend-down is used), tax laws may play a role in influencing key personal and life choices. Along similar lines, for people of all income levels, another key variable is availability and affordability of private long-term care insurance that does not force policyholders into nursing homes.
In the current discussion of health-care reform, access to insurance is a major issue. Although the tax code has already been used to enhance the ability of self-employed persons to pay for health insurance, what has been missing from the discussion are suggestions for ways that tax policy and other forms of positive leverage could likewise be used to increase the supply and quality of private long term care insurance that would help defray the costs of staying in one's own home. Various models of coverage, including partnerships between insurance and Medicaid, already exist, but other models that specifically emphasize the meeting of in-home and community-based care costs, rather than devoting their resources primarily to nursing homes, are needed.

So long as coverage tips the scales in favor of nursing homes by providing vastly smaller and patently inadequate benefits for home- and community-based services and by defining covered services in ways that further the bias in favor of institutional care, no viable private-sector participation in solving this problem is likely. NCD recommends that Congress should hold hearings and invite recommendations on coverage packages, including seller and purchaser incentives, that would help to meet the existing and foreseeable needs for greatly expanded private-sector participation in the financing of home- and community-based services and care.

State Initiatives

The coordination issues encountered in implementing Olmstead in the federal sector are mirrored at the state level and, indeed, depend in large measure on what the states do. Although some states have done very well (embracing Olmstead out of commitment and/or pragmatism), anecdotal evidence suggests that other states have followed a path of reluctance and resistance, perhaps going through the motions of planning but in the end putting few if any significant mechanisms into place. Whatever the explanation for the variation in states' responses, the fact that more than half the states have not moved effectively to implement Olmstead, more than three years after it was decided, raises troubling questions regarding both state capacity and federal commitment.

The prospect in many states of huge cuts in Medicaid to help close budget deficits adds further obstacles to Olmstead implementation and NFI success and further urgency to getting started. Waiver programs, proportionally perhaps even more than regular Medicaid, are likely to be affected by these cuts. While painful Medicaid cuts are inevitable, HHS and CMS should find means (within the scope of their regulatory and oversight authority) to identify the kinds of cuts least destructive to burgeoning Olmstead initiatives and should do everything possible to encourage states not to make these kinds of cuts. CMS should also provide additional technical assistance to states on what Title II of ADA requires and share exemplary state plans that have thus far been developed and put into effect.

More broadly, NCD recommends (See, http://www.ncd.gov/newsroom/publications/2003/
reclaimabridged.htm) that the Administration conduct and publish a comprehensive audit of all state-based Olmstead implementation activities, designed to describe what has worked, to identify states that have been successful or are trying as well as those that have not been successful, and to make certain that citizens and voters are as fully informed as possible about the values at stake in the responsiveness or unresponsiveness of their state officials and leaders. Anecdotal information about state responses to Olmstead suggests that neither partisan affiliation nor position of the state government on the ideological spectrum is a predictor of states' responses. Only when we know what has worked, why some states have embraced Olmstead and others not and why some have met with noticeably more success than others can we hope to engender the galvanized response so desperately needed if the transition and deinstitutionalization that Olmstead betokens can reach critical mass across our nation.

3. In your testimony, you describe the challenges inherent to the current system. For example, services that are essential to a quality of life in the community - affordable housing and accessible transportation - are often fragmented between Federal agencies. As home- and community-based services become more readily available, what can be done to improve coordination and promote independence for individuals with disabilities?

There are both short-term and long-term strategies to be considered to improve coordination and promote independence for individuals with disabilities. Some of the short-term strategies for consideration are listed above as NCD's response to question #2 from Chairman Grassley. The short-term strategies include: (a) (re)constituting relevant Federal interagency initiatives such as the ICCL with sufficient resources and the authority to accomplish or compel coordinated planning and implementation; (b) doing everything possible to encourage states not to make budget cuts that would negatively affect their Olmstead initiatives; and (c) CMS providing additional technical assistance to states on ADA Title II requirements, and sharing exemplary state Olmstead plans.

One long-term strategy idea that NCD currently is reviewing internally involves the concept of an Agency on Disability. Such a entity might be charged with administering the combination of long term support services, accessible housing, accessible transportation, employment supports, and assistive technology that people with disabilities need in order to live, work, and participate successfully in their communities.

An Agency on Disability might enable a more cost effective use of taxpayers' money by eliminating redundant bureaucracies, cost-shifting, and compartmentalized budgets. The following is an example of how compartmentalized budgets are not cost effective: A person with quadriplegia is at high risk for pressure sores from sitting in the same position all day. A wheelchair with a seat that can be tilted to different positions during the day can greatly reduce this risk. However, most State Medicaid DME (durable medical equipment) Department budgets cap the cost of a wheelchair at well below the cost of one with the tilt seat - despite the fact that the cost of such a wheelchair is substantially less than the cost of hospitalization and treatment for a pressure sore. This happens because the DME budget is separated from the acute care budget, so the benefit to the overall Medicaid program budget is ignored and overall costs to Medicaid escalate.

In addition, the separate funding streams and administrative bureaucracies for each Medicaid home- and community-based waiver, Intermediate Care Facilities, Assisted Living Facilities, and nursing homes make it extremely difficult for an individual to transition from one model of long term services and supports to another. Cost-shifting among various disability programs also occurs frequently, causing delays in service provision that can be life-threatening to consumers and result in greater costs to taxpayers because when an individual's heath care needs are not addressed in a timely way, health often deteriorates.

Creating an Agency on Disability that views the whole individual and oversees a comprehensive budget for long-term services and supports, acute care services, housing, transportation, employment, and assistive technology might result in more productive lives for people with disabilities and more cost-effective use of tax dollars. An additional benefit could be that under a comprehensive Agency on Disability, collecting and analyzing this essential data might be more effectively and affordably accomplished.

We intend to continue our consideration of this type of long-term strategy, as well as others, during the remainder of the fiscal year and will keep you apprised of our further thoughts and any recommendations on this issue.

From Senator Bunning:

1. There is a concern about the lack of access to quality medical, dental and other health services for people with mental retardation and developmental disabilities. Would you support using federal funding for the development of MR/DD clinics that deliver specialized care to the MR/DD population while also training future health care professionals?

Respectfully, Americans with disabilities in general are not able to access quality medical, dental and other health services in this nation. It is not just people with mental retardation and/or developmental disabilities who need access to better health care, it is all people with disabilities.

The United States has among the finest and most advanced health care in the world, but the systems for delivering that care to many of our citizens are under severe strain and, in some sectors, in crisis. The problems are no mystery, even if their solutions are elusive. These problems include shortages of adequate primary care (particularly in inner-city and rural areas); overuse of hospital emergency rooms in the face of a decline in the number of such facilities; rising insurance premiums in the private sector that preclude individuals from purchasing or employers from providing coverage; declining incomes and growing dissatisfaction among doctors; escalating scarcity of physicians willing to treat Medicaid or Medicare beneficiaries; opting out by managed care organizations from coverage in various areas and of various subgroups of the population; narrowing definitions of what is covered and increasing co-payments and deductibles (resulting in larger out-of-pocket costs to the fully insured); medical personnel who receive inadequate and insufficient training regarding disabilities; crushing prescription drug costs; and, most recently, sharp cutbacks in state Medicaid programs, among others.

By some estimates there are nearly four million adults and children with severe disabilities who are uninsured (e.g., Jack Meyer and Pamela Zeller, Profiles of Disability: Employment and Health Coverage, Economic and Social Research Institute for the Kaiser Commission on Medicaid and the Uninsured, September 1999). Accordingly, NCD believes that all Americans with disabilities need access to quality medical, dental and other health services, including people with mental retardation and/or developmental disabilities.

No one is satisfied with the current system, yet no one can bring forward anything approaching consensus recommendations for reform. Recognizing that in matters of accessibility, availability, affordability and adequacy of health care, persons with disabilities are the proverbial canary in the mineshaft, NCD has followed and contributed to the evolution of health-care policy for more than a decade. NCD is currently evaluating a range of promising community-based and consumer-oriented service and support reforms and initiatives. We believe that the results of our current policy research will also be of value to this Committee in the months ahead. NCD's current work includes: (a) an evaluation of federal and state initiatives in the area of consumer-directed reform through Medicaid and Medicare; (b) Livable Communities for people with disabilities and people who are elderly; and (c) Long-Term Services and Supports refinancing and systems reform.

2. There has been some concern about implementing new and expensive programs while some people are currently on waiting lists for services. Do you have any thoughts on addressing issues of the waiting lists?

Waiting lists are a direct function of the institutional bias of the Medicaid system and the very services authorized by Congress under Title XIX of the Social Security Act. If this bias were removed, and if long-term services and supports were instead mandated by Congress rather than maintaining the institutional bias, waiting lists would be less of a challenge. In that vein, while there may be an initial investment or outlay to change the bias away from institutional placement towards community placement, the ultimate goal is to provide consumer choice and direction in using the same federal dollars. The Olmstead Supreme Court decision requires that waiting lists move at a reasonable pace. Finally, greater numbers of young people should be encouraged to purchase long-term care insurance through the private sector.

3. Receiving community-based care is not an option for everyone. What type of factors should be considered when determining if home-based care or institutional care is best for a particular individual?

The classical view of the medical model is that a person with a disability has problems are caused by the fact of his or her disability, and whether or not the disability can be alleviated by the medical profession. This model implies then that the person with a disability must always trust members of the medical profession to make the right decisions for him or her, including choices regarding institutional versus community placement. It is NCD's view that the changing role of an individual with a disability in American society today involves greater responsibility, more empowerment, and choice. Individual choice is the key to the Senator's question.

The main thrust of the Americans with Disabilities Act and the Supreme Court's Olmstead decision is that people with disabilities have the same rights as other citizens to freedom, equality, equal protection under the law, and control over their own lives. These rights must be honored if people who have disabilities are to be fully included as valued citizens in the relationships and opportunities of community life.

As part of its research for NCD's 2003 report entitled Olmstead: Reclaiming Institutionalized Lives, we included interviews with informants with disabilities and their advocates. We asked what the person considered "the most integrated setting" for persons with disabilities. Almost without exception, the interviewees responded by naming the qualities that make home living meaningful and satisfying to the individual. Only two respondents named a type of program, such as a supported living arrangement or a two-person home. Response patterns were similar across all categories of disability.

The most common response was that the most integrated setting is "a place where the person exercises choice and control," including choice of service providers: "What people themselves want! ... Self-determination is essential. People decide for themselves what they want and need." A variation on this response was, "Whatever the person considers most integrated." The second most common response was, "A home of one's own shared with persons whom one has chosen to live with," or where one lives alone. The third most common response emphasized that home living for persons with disabilities should be like home living for other community members. Integration is "living in the community with everyone else like everyone else." Several respondents defined community integration as the result of participation in community activities or of the assumption by persons with disabilities of leadership roles in the community. And finally, one respondent defined community integration as affording opportunities for privacy, unlike an institution.

Similarly, when interviewees were asked what people with disabilities need to live in the most integrated setting, they responded, almost universally, not by listing formal services but by identifying ordinary human needs. Again, response patterns were similar across all disability groups. The most common response was that support depends on the person, must be defined by and tailored to the individual, and may change over time. The second most common response was that people need friendships, emotional support, and networks of friends, family, and mentors. Education, participation in community activities, and transportation were mentioned by a number of respondents.

Every person NCD interviewed who was affiliated with a disability organization stated that the organization had a position on the right to live in the community. Organizational positions on community living varied little from one disability group to another. Some stated that the right to live in the community is "absolute," and others that closure of institutions is their organization's highest priority. The following were other common positions:

• Everyone has the right to live in the community with support.
• People should live independently, not in a nursing home.
• We support the right to choose.
• We support self-determination.
• We support inclusive communities.

While at one time in America services and supports was generally only available in nursing homes and in private residences (for people with disabilities) with the help of informal family caregivers, there is now a continuum of care of options, including assisted living, adult day services and home health care. In addition to selecting the most integrated setting possible, when determining if home-based care or institutional care is best for a particular individual, the type of factors that should be considered includes, but is not limited to, the following:

• the individual's needs and preferences;
• the availability of formal and informal support services;
• whether the individual qualifies for public assistance, has long-term services and supports insurance, and, other income-related issues;
• how individuals and their families will be involved in decisions about the delivery of services and supports services;
• that home care services should supplement, not supplant family care giving;
• that increased access to respite services and training for family caregivers is needed to sustain their efforts and ensure that people receive care in the least restrictive setting possible;
• that people of all income levels should have access to necessary and appropriate services and supports with a sliding scale contribution.

If people who have economic needs require assistance, the default given to them through Medicaid is a nursing home or an institutional placement. It should be the other way around. The person first should be given the opportunity to live in the community. States should be obliged to provide assistance and supports in the community and then, only if there is no other alternative to community-based living, would states consider nursing home or institutional placement. This is essentially one way to effectively reverse the Medicaid institutional bias that dominates too many lives in America today. People are most productive and have the highest quality of life in an integrated community with friends and family members nearby.

From Senator Baucus:

1. In your view, how can we strengthen and bolster the Medicaid program to help states fully implement the Olmstead decision in the short and long term?

In NCD's 2003 report Olmstead: Reclaiming Institutionalized Lives, we asked the persons with disabilities whom we interviewed, "What policies could the states enact that would help people who do not need to be institutionalized live in the community?" The responses strongly and consistently favored self-determination and consumer-directed models of service. The respondents showed an awareness of how federal housing programs need to change to foster community integration, as well as the obvious changes that need to occur in the Title XIX program. Many people from all disability groups urged the passage of MiCASSA. Our respondents also advocated better information and training for people with disabilities and support and funding for self-advocacy. The responses include the following:

• Fund self-advocacy and add self-advocacy organizations to the "Big 3" [Administration on Developmental Disabilities] programs [the University Affiliated Programs, the Protection and Advocacy systems, and the Developmental Disabilities Planning Councils]
• Get rid of red tape; change Medical Assistance (MA) rules and guidelines
• Pass MiCASSA
• Make self-determination federal law
• Set aside Section 8 vouchers for people who are ready to leave nursing homes
• Tie a rent subsidy program to persons leaving institutions
• Shift Section 811, which traditionally has been a project-based funding source, to individual vouchers
• Assist people to live in homes with support staff
• Stop putting money into institutions and instead put it into housing.
• Provide essential therapies and communication
• Change professional and bureaucratic attitudes
• Provide more direct information sessions for people with disabilities to learn their rights
• Train people in institutions to learn how to live in the community; have "buddy systems"
• Provide more home-based programs
• Provide vouchers for homeownership
• Provide peer support
• Have flexible emergency response systems
• Provide vouchers for homeownership
• Provide better salaries for personal assistance providers
• Eliminate programs' institutional bias
• Provide more supported-living apartments
• Have better pay for front-line staff
• Have mandatory training for staff to overcome the outdated attitude that "I'm here to take care of you"
• Have more flexibility with waivers
• Provide equitable support for people with disabilities entering the workforce
• Allow people to earn higher wages without influencing benefits
• Give money to people and allow them to use it for support from family and friends, not agencies
• Provide education to communities that it is okay to be different

Our respondents' emphasis on flexible funding and on self-determination, choice, and control over how service dollars are spent are reflected in service models based on self-determination, consumer direction, and direct control of service dollars. These models are not necessarily new-the Centers for Independent Living (CILs) and the mental health consumer/survivors' self-help movement have been providing consumer-controlled services for the past two decades. Indeed, most of these service models are strongly supported by scientific studies of their outcomes for consumers.

In addition, the following are some of the many examples suggested by NCD's Olmstead report of promising practices in the design, delivery, and financing of community services that are consistent with the Olmstead decision.

• Good practice in Olmstead planning. Indiana's recent plan assigns each recommendation to one of three categories: (1) those that should be implemented quickly and with little or no fiscal impact or regulatory requirements; (2) those that should be implemented quickly but have a fiscal impact or require regulatory changes; and (3) those that are more complex, costly, or difficult and will require more time to develop and implement. Indiana's plan should serve as a model for other states. Nevada's Olmstead plan is commendable for its candid analysis of the state's compliance with Olmstead.
• Overcoming incentives to unnecessary institutionalization. Methods include Maine's use of pre-admission screening by an independent agency prior to nursing facility placement, Minnesota's legislation encouraging nursing facility operators to take beds out of service, and Washington's system for tracking reduction targets for nursing facility placements.
• Identification and transition of people with disabilities from institutions. Disability rights advocates are doing the work of identifying people in nursing facilities who could move to more integrated settings in Colorado and Kansas.
• Use of trusts and fine funds to finance transition costs and start-up of community services. A creative and under appreciated set of strategies for financing transition costs, providing "bridge funding," and funding new community services involves the creation of trusts and fine funds dedicated to the needs of people with disabilities. North Carolina, Oregon, and Washington have used the proceeds from the sale of state facilities to establish trusts to generate funds for people with disabilities.
• Housing strategies. Commendably, and in large part because of the influence of the technical assistance provided by HHS's Office of Civil Rights (OCR), the more recently developed plans tend to reflect the input of housing agencies. Provisions for requiring universal design in new units that state housing agencies fund or finance; ensuring that all existing publicly financed housing has completed Section 504/ADA self-evaluations; conducting utilization reviews to ensure that targeted Section 8 programs are fully used; and including home modifications and home repair in the services provided under home- and community-based waivers and independent living programs are examples of housing-related recommendations in state Olmstead plans.
• Single point of entry systems. Single point of entry structures have the potential to reduce unnecessary institutionalization by providing easier access to a wider array of community services. Single point of entry systems that separate assessment and service brokerage from service provision are also responsive to findings of the Centers for Medicare and Medicaid Services (CMS) in a number of states that Medicaid beneficiaries' right to choose among qualified providers was violated.
• Beyond institutional closure: Increasing community integration. Developmental disabilities services in Vermont and New Hampshire show that "the most integrated setting" is more than placement in a residence outside an institution; rather, it is a continuous process of increasing community inclusion. These states' service systems have progressed far beyond institutional closure and are eliminating group homes in favor of living in a companion home or a home of one's own and working at a real job with support.
• Self-determination. Self-determination and consumer-directed service models have been so broadly tested and practiced that they have emerged as fundamental principles in human services.

The Olmstead decision has become a powerful impetus for a national effort to increase community-based alternatives and eliminate unjustified institutional placements. We must continue to empower Olmstead stakeholders in their efforts to redesign the state service systems to enhance choice, independence, self-determination, and community integration. Ultimately, there may be a need to carve out a Long-Term Care Title in the Act.