Preceding chapters focused on a specific care delivery strategy and discussed the Medicaid benefits and financing mechanisms. During the study, we also encountered issues of a more general nature that will affect developments regardless of which service delivery and Medicaid financing mechanisms are chosen. Actions and decisions related to the Supreme Court's 1999 Olmstead decision are one of these, directly affecting programs in several of our case study sites and potentially affecting every state and community in different ways.
A second global challenge is workforce adequacy--whether enough and the right kinds of workers will be available to serve the newly eligible Medicaid population in general and special needs populations in particular. Additional global challenges concern two special populations: people whose disabling health conditions and challenges to housing stability are primarily related to substance use disorders, for whom there are relatively few Medicaid-covered services available in PSH, even for Medicaid beneficiaries, and recipients of both Medicare and Medicaid (dual-eligibles), for whom service coordination is extremely difficult despite coverage by two health insurance programs.
We also identified approaches with particular promise that are still on the drawing board or were submitted to CMS and awaiting approval or comment during the study period. Most of these involved designs for health homes to serve persons with specific health conditions, as enabled by the Affordable Care Act. Also of great interest are the efforts of some states to include housing stabilization services as a covered benefit.