How the system works
Ten plain-language briefs on how services for people with intellectual and developmental disabilities work: the history and law behind community living, how services are funded and rationed, and the rules that shape daily support.
10 of 10 published
Part 1 ·
Institutions to community: Willowbrook, Pennhurst, SouthburyIn 1967, 194,650 people with I/DD lived in large state institutions. Most of those places have closed, but Connecticut's Southbury still houses 84 people. How three institutions shaped today's community services and DSP jobs, as of September 2026.
Part 2 ·
Olmstead v. L.C.: what it requires, how it's enforcedThe 1999 Olmstead ruling says needless institutional isolation is disability discrimination. As of September 2026 it still stands, but federal enforcement has shifted. What it requires, how Georgia and Virginia settlements put it to work, and what changed in 2026.
Part 3 ·
Medical vs. social model of disability, explainedThe medical model locates disability in the person; the social model locates it in barriers around them. WHO's ICF blends the two, and U.S. rules mix both as of September 2026. What each model means for eligibility, support plans and a DSP's daily work.
Part 4 ·
Medicaid FMAP: how federal and state money pays for I/DD servicesIn fiscal 2027, which starts in October 2026, the federal share of most Medicaid costs ranges from 50% to 77.32% by state, and states pay the rest. How that match works, where the state share comes from and how the money reaches I/DD providers, as of September 2026.
Part 5 ·
HCBS waiting lists: why people with I/DD waitAbout 649,900 people were on Medicaid home care waiting or interest lists in 40 states in 2026, about 7% more than in 2025. Most have I/DD. Why the lists exist, how states decide who comes off them, how long people wait and what the numbers miss, as of October 2026.
Part 6 ·
HCBS settings rule: what 42 CFR 441.301(c)(4) requiresThe HCBS settings rule requires Medicaid community services to protect privacy, choice and community access. States' transition ended March 17, 2023. What it requires, how limits must be justified and where it stands as of September 2026.
Part 7 ·
Self-direction and FMS in Medicaid, explainedMore than 1.5 million people self-directed their home care in 2023, mostly through Medicaid, with FMS handling payroll. How employer and budget authority work, who the legal employer is, and when family can be paid, as of September 2026.
Part 8 ·
Aging out of IDEA: what ends at 21 or 22Federal special education rights can last until about age 22, but adult disability services carry no such guarantee. What IDEA requires before school ends, how states differ and what adult systems come next, as of September 2026.
Part 9 ·
HCBS oversight: critical incidents, surveys and fraud unitsFederal rules require states to protect health and welfare in I/DD services, with new HCBS incident rules due July 9, 2027. Who oversees providers, how critical incidents and ICF/IID surveys work and what fraud units do, as of September 2026.
Part 10 ·
Medicaid rate studies: how DSP wages get into ratesA 2025 Virginia rate study built a $22.20 hourly DSP wage into proposed I/DD waiver rates, then added benefits, supervision and overhead. How rate studies work, how rate wages relate to pay and the federal rate rules in place as of September 2026.