The brief provides the historical context as well as a summary of the recent policy environment, which has fostered the shift in Medicaid policy away from institutional care toward home- and community-based services. By examining trends in long-term care, the Olmstead decision, the Deficit Reduction Act and programs such as Money Follows the Person and California's Real Choices System Change grant, the brief offers a vision for the future of home- and community-based services and the role of consumer choice in states' long-term care policies.