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California's Attempt to Cut Adult Day Health Care Services is Blocked by Court

The U.S. District Court for the Northern District of California prohibited California from implementing its proposed cuts to Adult Day Health Care Services (ADHC).

Responding to a state budget crisis, the California Legislature made devastating cuts to Medicaid and a variety of health programs, including Adult Day Health Care. In conjunction with AARP California's earlier efforts to limit the cuts, AARP attorneys, in conjunction with attorneys from Disability Rights California and the National Senior Citizens Law Center, filed a class action lawsuit on behalf of older plaintiffs with disabilities to block the cuts in ADHC services.

ADHC provides daytime health and nursing care and other services to low-income people with disabilities, enabling them to remain in their homes and communities. The 35,000 Californians who participate in ADHC have an average age of 78 years and take six or more medications per day, requiring supervision or assistance, nursing and related services. More than two-thirds of the recipients also face at least three serious medical challenges (such as cardiovascular disease, dementia or diabetes), and 92 percent of the recipients are entirely dependent on Medi-Cal funding for their care and cannot afford to pay for these lifesaving services themselves.

The California Legislature, in action opposed by AARP California, made substantial cuts to the state's Medicaid program, including cuts to the ADHC program. The cuts would result in individuals, who have been assessed by the state and their treating professionals to medically need four or five days of ADHC a week, receiving this vital service no more than three days per week. According to the statute that implements the cuts, the state could also by written declaration implement eligibility restrictions that could result in complete termination of services to some individuals. Services that are provided by ADHC include professional nursing services, personal care services, medication management, meals and physical therapy.

California's Medicaid program, also known as Medi-Cal, is the main source of health care insurance for 6.6 million Californians. As with all Medicaid programs, once enrolled in the federal-state partnership, the state agrees to provide a basic array of and level of services to its lowest-income residents. One bedrock principle is that medical services must be provided to beneficiaries at least to the extent that those services are available to the general population living in the same geographic area, and that the amount, duration and scope of each covered service sufficiently or reasonably achieves its purposes. In exchange for this commitment, the federal government pays a significant share of the costs of the health insurance program.

Plaintiffs' Arguments

The plaintiffs in Brantley v. Maxwell-Jolly (also referred to as Cota v. Maxwell-Jolly, and now Darling v. Douglas) argue that California's enacted cuts violate federal Medicaid law and the Americans with Disabilities Act (ADA). The cuts subject class members to unnecessary institutionalization by failing to provide health services in the most integrated setting appropriate to an individual's need — which would thus enable class members to remain in their communities. California admits that the proposed cuts in services and benefits and changes affect as many as 8,000 individuals currently receiving five-day-a-week ADHC care.

Among the people affected by the cuts is named plaintiff Lillie Brantley, an 84-year-old woman with Alzheimer's and a seizure disorder, who has had a stroke and is very frail. She needs supervision with feeding and transferring as well as assistance bathing, dressing and toileting, and is completely dependent on others for housework, laundry, shopping, medication, money management and meal preparation. Brantley currently receives professional nursing services to monitor her condition, personal care services to help with hygiene and feeding needs, and therapeutic services to increase her interactions with others and reduce her isolation as well as to help her maintain her functional strength. Brantley resides with relatives and is a member of her local community and church. She and her family want her to remain there, but her niece, who is her primary caretaker, must work full time and, consequently, Brantley is only able to remain in the family home with the assistance of ADHC services. Her only alternative, if ADHC services were cut back, would be institutionalization — to her detriment (studies document rapid deterioration when frail older people are moved to unfamiliar environments), against her wishes and the wishes of her caretaker family, and at significantly higher costs for the State of California.
Gilda Garcia, another plaintiff, is 77 years old with unstable diabetes, hypertension, Bells' palsy and kidney problems. She uses a cane and needs help with transferring, bathing, meal preparation, shopping, transportation, housework and laundry. However, she enjoys living in her home and in her community, enjoys her interactions and social activities, and wants to remain there. ADHC services provide her personal care services, professional nursing services, leisure opportunities, physical therapy and dietician services five days a week. Without ADHC, it is inevitable that she would have to be in an institutional setting because of her unstable diabetes.
In addition to challenging the actions that would be taken if the law is allowed to take effect, plaintiffs challenge the notice that was sent by the state about the changes, arguing that it violates their statutory rights under Medi-Cal. Plaintiffs asked the federal court to prevent the law from taking effect while this lawsuit is pending, and ultimately, to rule that the California budget cuts violate Medicaid law and the ADA.

The Court's Ruling

Ruling that ADHC recipients were at serious risk of institutionalization and "particularly irreparable and imminent" harm, the court issued a preliminary injunction that prevents the cuts from taking place while the lawsuit is pending.

The court went to say that the state has "taken an arguably cavalier approach to ensuring their continuing compliance with the ADA and Rehabilitation Act" and had done no more than show a "theoretical" availability of alternative services. These minimal showings, the court ruled, were insufficient to guarantee the safety of ADHC recipients. "Given the tenuousness and complexities of their conditions, an interruption in their care, even if temporary, will have serious consequences for Plaintiffs," the court ruled.

A separate lawsuit, in which AARP Foundation Litigation attorneys have filed AARP's "friend of the court" brief on behalf of health care providers, challenges other elements of the state's budget cuts regarding reimbursement of health care service providers, and is proceeding through the courts as well.

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