Olmstead v. L.C. U.S. Supreme Court, No. 98-536 527 U.S. 581 (1999)

1. Olmstead v. L.C.U.S. Supreme Court, No. 98-536 527 U.S. 581 (1999) • “[W]e confront the question whether the proscription of discrimination may require placement of persons with mental disabilities in community settings rather than in institutions.” • “The answer … is a qualified yes.”

2. The “Integration Mandate” of the Americans with Disabilities Act28 C.F.R. Section 35.130(d) • “A public entity shall administer services, programs and activities in the most integrated setting appropriate to the needs of qualified individuals with disabilities.”

3. “Reasonable Accommodations”28 C.F.R. Section 35.130(b)(7) • “A public entity shall make reasonable accommodations in policies, practices and procedures … • unless … making the modifications would fundamentally alter the service, program or activity.”

4. Who brought the case? • Two women, Lois Curtis and Elaine Wilson, who were institutionalized at Georgia Regional Hospital … • sued Tommy Olmstead, the Commissioner of the Georgia Department of Human Resources

5. The Trial Court Decision1997 WL 148674 (N.D. Ga. 1997) • Ruled for Ms. Wilson & Ms. Curtis • Found that Georgia “could provide services to [Ms. Wilson & Ms. Curtis] in the community at considerably less cost than is required to institutionalize them.”

6. Court of Appeals Decision138 F.3d 893 (11th Cir. 1998) • Sent the case back to the trial judge on cost of community care • Asked “whether the additional expenditures … would be unreasonable given the demands of the State’s mental health budget.”

7. The Supreme Court:Why is institutionalization discriminatory? • “First, institutional placement of persons who can handle or benefit from community settings … perpetuates unwarranted assumptions … that persons so isolated are incapable or unworthy of participating in community life.”

8. The Supreme Court:Why is institutionalization discriminatory? (2) • “Second, confinement in an institution severely diminishes the everyday life activities of individuals, including: • Family relations, • Social contacts, • Work options, • Economic independence, • Educational advancement, and • Cultural enrichment.”

9. When is community placement required? • When “the State’s treatment professionals have determined that community placement is appropriate, • the transfer from the institution to a less restrictive setting is not opposed by the affected individual,

10. When is community placement required? (2) • and the placement can be reasonably accommodated, taking into account • the resources available to the State • and the needs of others with disabilities.”

11. When may State refuse to serve person in the community? • When the State, “generally rely[ing] on the reasonable assessments of its own professionals,” determines that habilitation needs can only be met in an institution.

12. When may State refuse to serve person in the community? (2) • When “in the allocation of available resources, immediate relief … would be inequitable, given the responsibility the state has undertaken for the care and treatment of a large and diverse population of persons with disabilities.

13. If immediate community placement is impossible, what must the State do? “If the State were to demonstrate that it had • a comprehensive, effectively working plan for placing qualified individuals with disabilities in less restrictive settings, • and a waiting list that moved at a reasonable pace, not controlled by the State’s endeavors to keep its institutions fully populated, the reasonable-modifications standard would be met.”

14. What do we consider in terms of the State’s other obligations? • “[T]he range of facilities the State maintains for the care and treatment of persons with diverse mental disabilities, • and its obligation to administer services with an even hand.”

15. No “dumping” allowed • “Nor is it the ADA’s mission to drive State’s to move institutionalized patients into an inappropriate setting, such as a homeless shelter.”

16. Limits on community placement: Persons who “can’t be placed” • “We emphasize that nothing in the ADA or its implementing regulations condones termination of institutional settings for persons unable to handle or benefit from community settings.”

17. Limits on community placement (2):Persons who don’t want to leave • “Nor is there any federal requirement that community-based treatment be imposed on patients who do not desire it.”

18. Persons in Long-Term Care Facilities Source: Centers for Medicare and Medicaid Services

19. Total Nursing Home Population in the United States: ~1.35 Million SOURCE: CMS Minimum Data Set 2.0 (1st Q 2010)

20. Who Pays? • Medicaid: 54% (729,000) • Medicare: 25% (337,500) • VA: 1% (13,500) • Self/family: 13% (175,500) • Private insurance: 9% (121,500) SOURCE: CMS MDS 2.0

21. How much are we spending?Medicaid Expenditures, FY 2008SOURCE: CMS 64 data Institutional Spending: • Nursing Homes: $49 Billion • ICF/MR (for persons with developmental disabilities): $12 Billion Community Spending: • Home and Community services (waivers, all disabilities): $30 Billion • Personal Care option: $11 Billion • Home Health: $4 Billion Total: $61 Billion Total: $45 Billion

22. Age of Nursing Home Residents • Under 30: .5% (6,750) • 31 to 64: 14% (189,000) • 65 to 74: 14% (189,000) • 75 to 84: 28% (378,000) • Over 85: 50% (675,000)

23. From where do people enter nursing homes? (Top three) • An acute care hospital: 61% • Another nursing home: 13% • A private home with no home health services: 10% SOURCE: CMS MDS 2.0 (1st Q 2010)

24. How many residents want to return to the community? • United States: 23% (310,500) • California: 27% (26,460) • Illinois: 25% (18,250) • Louisiana: 16% (4,000) • Michigan: 30% (11,700) • New York: 21% (22,260) • Oregon: 35% (2,555) • Texas: 20% (18,600) • Utah: 37% (1,872) SOURCE: CMS MDS 2.0 (1st Q 2010)