The Americans with Disabilities Act (ADA) offers legal protection to individuals with disabilities facing discrimination in employment, public accommodations, and services provided by the telecommunications, transportation, and public sectors. Its stated purpose is "to provide a clear and comprehensive national mandate for the elimination of discrimination against individuals with disabilities." Title II of the ADA states in part that "no qualified individual with a disability shall, by reason of such disability, be excluded from participation in or be denied the benefits of the services, programs, or activities of a public entity, or be subjected to discrimination by any such entity." A public entity is defined as a state or local government. The Department of Justice (DOJ) has promulgated detailed regulations for Title II. One of these regulations, the so-called integration regulation, interprets Title II to mean that "a public entity shall administer services, programs, and activities in the most integrated setting appropriate to the needs of qualified individuals with disabilities." However, the integrated setting is not required if "the public entity can demonstrate that making the modifications would fundamentally alter the nature of the service, program, or activity." In Olmstead v. L.C. , 527 U.S. 581 (1999), the Supreme Court held that, under Title II of the ADA and the integration regulation promulgated by the DOJ, state action to unjustly isolate people with disabilities is a form of prohibited discrimination. Since then, appellate courts have more clearly articulated states' Olmstead obligations. In addition to these judicial developments, the recent health care reform package, the Patient Protection and Affordable Care Act (PPACA, P.L. 111-148 ) as amended by the Health Care and Education Reconciliation Act (HCERA, P.L. 111-152 ) (collectively the Affordable Care Act, or ACA), has the potential to influence states' Olmstead initiatives. Specifically, the Affordable Care Act revised the federal Medicaid statute to give states greater incentives to provide home and community-based care services to people with disabilities, offer states greater flexibility in the kinds of packages of home and community-based services they can offer, and, perhaps, enable states to provide more Medicaid beneficiaries with long-term care services in their communities. Because judicial developments under Olmstead often take federal Medicaid law into account, PPACA amendments to that law may affect the outcome of future cases on deinstitutionalization. In Olmstead v. L.C. , the Supreme Court held that "unjustified isolation ... is properly regarded as discrimination based on disability" under Title II of the ADA and its implementing regulations. The plaintiffs in Olmstead were mentally disabled individuals who were voluntarily confined to a state hospital's psychiatric unit. Their physicians had determined that they were capable of living in a community-based environment. Georgia refused to transfer the individuals to a less restrictive setting, although the programs were available. The plaintiffs then brought suit under the ADA arguing that their segregation in the state institution violated Title II of the act. Georgia argued that its actions did not fall within the ADA's concept of discrimination because it had decided to keep the plaintiffs in institutions not because of their disabilities but because of other factors. In addition, Georgia claimed that the federal Medicaid statute (42 U.S.C. §1396 et seq. ) "reflected a congressional policy preference for treatment in the institution over treatment in the community." The Court rejected Georgia's arguments, holding that the ADA reflects a "more comprehensive view of the concept of discrimination." Specifically, the Court held that the ADA defines discrimination to include the unjustified segregation of individuals with disabilities and thereby requires states to provide community-based treatment for persons with mental disabilities when three conditions are satisfied: (1) the state's treatment professionals determine that such placement is appropriate, (2) the affected persons do not oppose it, and (3) the placement can be reasonably accommodated given the state's resources and the needs of others with mental disabilities. Regarding the third condition, the Court held that requiring community-based care is not a reasonable accommodation if, because of budgetary constraints, it would fundamentally alter the state's services and programs by forcing the state to mete out its mental health services inequitably. In Part III-B of the Olmstead opinion, a plurality set a benchmark by which the reasonableness of the state provision of community care to the plaintiffs could be assessed. The plurality stated that to determine whether the provision of community care is a reasonable accommodation to, or a fundamental alteration of, the state's services and programs, a plaintiff's request must be reviewed in the context of the state's responsibility for the care and treatment of its disabled population as a whole. From this viewpoint, neither a state's marginal cost of placing the plaintiff nor the immediate placement of all qualified persons is the touchstone. Instead, a state could satisfy its obligation if, because of budget constraints, it maintains a waitlist of qualified persons needing community placement so long as the waitlist moves at a "reasonable pace not controlled by the [s]tate's endeavors to keep its institutions fully populated" and is part of a "comprehensive, effectively working plan for placing qualified persons … in less restrictive settings." Early case law interpreting Olmstead focused primarily on the complaint: what does a plaintiff need to allege to establish a prima facie case that a state failed to fulfill the ADA's integration requirement? More recent case law, however, has focused on the defense: what does a defendant need to prove to show that providing the services requested would necessitate a fundamental alteration of its programs and services? The appellate courts have generally rejected interpretations of Olmstead that would make it more difficult for plaintiffs to establish a prima facie case that the state has failed to fulfill the ADA's integration requirement. Accordingly, they have held that a prima facie violation of the ADA's integration requirement may exist even absent allegations that (1) the state placed or held the qualified individuals in an institution, (2) the state uses disability-specific criteria to decide who is eligible for community-based services, or (3) the plaintiffs are eligible to receive the requested services under state law. Several of these cases are considered below. In Fisher v. Oklahoma Health Care Authority , the Court of Appeals for the Tenth Circuit considered whether Olmstead only obligated states to integrate individuals who, because of state action, were placed or held in institutions. The court ruled that state action to place or hold qualified individuals in segregated settings is not a necessary element of a prima facie violation of Title II of the ADA. Instead, Olmstead applies not only when a state places or holds a qualified person in a facility but also when a state prevents a qualified person from receiving services in an integrated setting. In that case, the Oklahoma agency responsible for administering the state's Medicaid program decided to fully fund nursing home residents' prescription medicines, but to fund only five prescription medicines per month for Medicaid recipients in community-based care. In its motion for summary judgment, the state argued that the plaintiffs could not maintain a claim under the ADA because the state had not placed them in, nor forced them to enter, an institution. The court disagreed, suggesting that if a state action has the effect of compelling persons with disabilities to move into institutions, a court could find that the state failed to satisfy the integration requirement of the ADA. In Townsend v. Quasim , the Court of Appeals for the Ninth Circuit considered whether plaintiffs must allege that the state excluded the plaintiffs from the community because of their disabilities. The court ruled that Olmstead did not require plaintiffs to allege that, but for their disability, the state would have integrated them into the community. Instead, a state could be found to have discriminated against plaintiffs even if the state segregated them for disability-neutral reasons. At issue in Quasim was a Washington State regulation effectively barring disabled persons with income above a certain level from community-based Medicaid services. Although the plaintiff had been receiving community-based care, once his income increased above that level, Washington asked him to choose between moving into a nursing home or foregoing his community care. In its motion for summary judgment, Washington argued that the ADA permitted states to bar certain disabled individuals from community-based care so long as it did so on the basis of disability-neutral criteria, such as an individual's income level, rather than on the basis of the individual's disabilities. The court disagreed, writing that even the application of disability-neutral eligibility criteria can be a form of disability-based discrimination if it causes qualified people with disabilities to receive services in unduly restrictive settings. States are obligated under Olmstead to make reasonable modifications to the criteria they use to determine which disabled individuals are eligible for community-based care. Accordingly, the court held that Washington should be found in violation of the ADA unless it could show that providing the requested services would fundamentally alter the nature of its Medicaid program. Finally, in Radaszewski v. Maram , the Court of Appeals for the Seventh Circuit considered whether plaintiffs must allege that, under state law, they are "qualified" to receive community-based services. The court ruled that plaintiffs had sufficiently alleged that they were "qualified" to receive community care without asserting that they were eligible to receive it under state law. At issue in Radaszewski were Illinois regulations that provided at-home care to disabled individuals under the age of 21, but barred the provision of that same care to disabled individuals 21 or older if the cost of providing it exceeded a set amount. The plaintiff, the mother of a boy who had been severely disabled since the age of 13, filed suit against the state under the ADA when she was told that, because of these regulations, her son would have to move into an institution in order to continue receiving state funded round-the-clock care. The state argued that the plaintiff's complaint was deficient because it failed to allege that her son was "qualified" to receive community-based services under the state's rules of eligibility.