When Services Exist on Paper But Not in Practice

The real accessibility crisis isn't a ramp or a website. It's 85% of disability service providers reporting staffing shortages so severe that people with developmental disabilities are being turned away from services they legally qualify for — services that exist on paper but are becoming impossible to reach in practice.

That's the finding from ANCOR's 2025 annual survey (opens in new window) of 524 intellectual and developmental disabilities (IDD) service providers across every U.S. state and Washington, D.C. The numbers aren't new — ANCOR has been tracking this deterioration for years — but the scale of collapse they document this cycle is different. The system hasn't just strained. It has, as ANCOR CEO Barbara Merrill put it, reached "a dangerous equilibrium where crisis conditions have simply become the norm."

For practitioners working in Title II compliance and disability rights, this report deserves careful attention. It describes a systemic access failure that no physical accommodation checklist or digital audit can fix.

What the ANCOR Survey Data Shows

The ANCOR survey findings map a cascading failure across the IDD service system:

Indicator	Percentage of Providers Reporting
Moderate or severe staffing shortages	85%
Declined new referrals due to staffing	55%
Cut programs or services for existing clients	29%
Held off on launching new programs	50%+
Considering additional program cuts	48%
Opted not to expand services due to Medicaid cut threat	56%
Serve areas with few or no alternative providers	~60%
Would end services within 3 months of Medicaid payment pause	~50%

These aren't projections. They're operational realities being reported right now by the organizations responsible for delivering home and community-based services — the residential habilitation, home-based support, and day habilitation programs that allow people with severe disabilities to live in their communities rather than institutions.

ANCOR's director of policy and regulatory affairs, Tom Rice, stated it plainly: "services for the disability community may appear to exist on paper, but will become impossible to access in practice."

That phrase — impossible to access in practice — is the compliance and civil rights issue here.

The CORS Framework Applied to a System Crisis

When accessibility professionals use the CORS framework — evaluating Community input, Operational capacity, Risk/legal priorities, and Strategic alignment — we typically apply it to a single organization's compliance posture. This situation demands applying it to an entire service ecosystem.

Community: Who Is Actually Affected

The people at the center of this crisis are individuals with intellectual and developmental disabilities who rely on Medicaid-funded home and community-based services (HCBS) for daily functioning. Many require 24-hour support. Many live in areas where, per the survey, "few or no alternate options exist." When their provider cuts services or closes a waitlist, there is no backup option.

The immigration enforcement dimension compounds this directly. Immigrants account for approximately 30% of the direct care workforce, according to ANCOR's findings. Federal enforcement actions are reducing the available labor pool in a field already operating at critical shortage. The community impact isn't hypothetical — it's already showing up in the 55% of providers who have declined new referrals.

Operational Capacity: Breaking Point Reached

The operational picture is stark. Nearly half of providers are considering additional program cuts. Half of those offering case management report struggling to connect people with services. And approximately half of all providers say they would have to end services within three months if faced with a pause or delay in Medicaid payments — the kind of payment delay that federal anti-fraud enforcement has already begun producing.

This is what organizational capacity failure looks like at scale. The compliance framework paradox we see in digital accessibility — where organizations become paralyzed by overlapping requirements — has a direct analog here: providers are simultaneously managing staffing crises, Medicaid payment uncertainty, state-level funding threats, and federal policy changes. The cognitive and operational load is unsustainable.

Risk and Legal Obligations: The ADA Does Not Pause for Budget Shortfalls

Here's the legal reality that state agencies and Medicaid-funded providers need to understand clearly: Title II of the ADA (opens in new window) and Section 504 of the Rehabilitation Act (opens in new window) require that public entities provide equal access to programs and services. Funding constraints do not eliminate that obligation.

The DOJ's integration mandate (opens in new window) — rooted in the Olmstead v. L.C. decision — requires states to provide community-based services to people with disabilities when those services are appropriate, desired, and can be reasonably accommodated. A state that cuts HCBS funding in ways that force people back into institutional settings faces real Olmstead exposure.

The risk triage here is immediate. States considering Medicaid HCBS cuts should be analyzing their Olmstead compliance posture before those cuts take effect, not after a DOJ complaint is filed. The settlement trap is real — legal action after the fact rarely restores services that have already been dismantled.

Strategic Alignment: Connecting Policy Levers to Outcomes

The strategic alignment challenge is connecting what policymakers care about — budget, efficiency, fraud prevention — with what the disability community needs: stable, adequately funded direct support. The ANCOR data provides the bridge.

The fiscal argument is strong. Home and community-based services cost significantly less than institutional care. Cutting HCBS funding to reduce Medicaid spending is, in most analyses, a strategy that increases long-term costs by pushing people toward more expensive institutional placements. That's an argument that can move budget-focused legislators if it's framed correctly.

The workforce argument is similarly concrete. Direct support professionals are chronically underpaid relative to the complexity and responsibility of their work. Medicaid reimbursement rates set the ceiling for what providers can pay workers. A policy conversation that treats DSP wages as a line-item cost rather than a workforce infrastructure investment will keep producing the same staffing crisis ANCOR has documented year after year.

Concrete Actions for Practitioners

If you're working in disability rights advocacy, state-level compliance, or policy:

Audit your state's HCBS waitlist data now. Many states maintain public data on Medicaid HCBS waitlists. Rising waitlist numbers, combined with provider survey data showing referral declines, create a documented record of access failure that supports both advocacy and legal action.

Map Olmstead exposure for your state. States that receive federal Medicaid funding and are considering HCBS cuts should be conducting Olmstead self-assessments. The ADA National Network (opens in new window) provides technical assistance on Olmstead compliance. The Southwest ADA Center (opens in new window) and Southeast ADA Center (opens in new window) both offer resources for state agency compliance analysis.

Connect the workforce crisis to the civil rights frame. ANCOR's data gives advocates concrete numbers to attach to what is fundamentally a civil rights argument: that people with disabilities have a legal right to community integration, and a system that cannot staff itself cannot deliver that right.

Monitor Medicaid payment delays as an immediate risk. The finding that nearly half of providers would have to end services within three months of a Medicaid payment pause is a specific, immediate risk. Federal anti-fraud enforcement is already producing payment delays. This is not a future scenario.

The Bottom Line

The ANCOR survey documents something that compliance checklists cannot capture: access failure that is structural, not architectural. No ramp fixes a provider that has closed its waitlist. No accessible website restores a day program that shut down due to staffing.

The disability community's right to equal access — grounded in the ADA, in Olmstead, in Section 504 — doesn't disappear when systems become overwhelmed. But rights without functioning services are, as Tom Rice said, impossible to access in practice.

The practitioners and advocates reading this have work to do at the policy level, not just the compliance level. The data is there. The legal framework is there. The question is whether the strategic alignment exists to use both before the system absorbs another shock it has no capacity to absorb.