Several challenges encountered during the study are not specific to particular Medicaid provisions or service mechanisms, but are likely to affect developments regardless of the ways states might choose to serve people with complex health care needs. Actions and decisions related to the Supreme Court's 1999 Olmstead decision present an opportunity but also a challenge, directly affecting programs in several of our case study sites and potentially affecting every state and community in different ways. Impacts may involve preferred housing configurations, tenant mix, and overall PSH system capacity and prioritization for tenancy.
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.
Two additional global challenges concern special populations that are not well-served by current arrangements--people with primary diagnoses of substance use disorders, for whom benefits may be limited even if they are Medicaid-eligible, and recipients of both Medicare and Medicaid ("dual-eligibles"), for whom service coordination is difficult despite coverage by two health insurance programs.