Oregon has long been recognized as a policy leader in long-term services and supports for vulnerable people and has created a system that values choice, independence, safety, and health. As the first state in the nation to gain a home and community-based services (HCBS) Medicaid waiver, Oregon has pioneered many innovative approaches to providing services in the community to people who would otherwise live in an institutional setting. Continuing with this trend, Oregon became the second state in the nation to implement the Community First Choice Option of the Affordable Care Act. The resulting K Plan opened the door to providing more home-based services to children with intellectual and developmental disabilities (I/DD), allowing families to access services before being pushed into crisis situations. It also expanded access to in-home services for adults, so those who want to continue to live with family or in their own homes can, even if they have high levels of need. These innovations, along with dramatic and rapid growth in the number of people enrolled in programs and services have increased the scale of service delivery and fundamentally changed the policy, funding, and regulatory structure of Oregon’s I/DD system. At the same time, the system as a whole has struggled with the rapid pace of change and has yet to adjust to how it needs to operate to support this new reality. The bottom line: Oregon is spending significant resources managing a complex and entrenched system while trying to address challenges on multiple fronts.