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Olmstead v. L.C.

An Overview and Description of the U.S. Supreme Court Decision

Prepared by:
Robert (Bobby) Silverstein
Center for the Study and Advancement of Disability Policy (CSADP)
1331 H Street NW, Suite 301
Washington, DC 20005
Phone: (202) 783-5111 (Voice/TTY)
E-mail: Bobby@CSADP.org

Set out below is an overview of the goals of the ADA and the major policies addressed in the Supreme Court decision in Olmstead v. L.C., followed by a narrative outline of the facts, posture, issues, holding, and analyses by and positions taken in the case by Justices of the Supreme Court.

  1. OVERVIEW OF THE ADA AND THE OLMSTEAD DECISION
    1. Goals of the ADA. The goals of the ADA include ensuring equality of opportunity, full participation, independent living, and economic self-sufficiency for individuals with disabilities of all ages. Major concepts embedded in the ADA include individualization; genuine, effective, and meaningful opportunity; inclusion; and empowerment (real, informed choice).
    2. Major Points in the Decision.
      1. "Unjustified institutional isolation" is a form of discrimination that constitutes an abridgement of a person's basic civil rights. The Supreme Court found that unjustified isolation and segregation of persons with disabilities in institutional settings is a form of discrimination prohibited by the ADA.
      2. The conceptual underpinning of the decision is that people with disabilities cannot be forced to choose between the receipt of appropriate medical services and the relinquishment of basic civil rights. People with disabilities cannot be forced to relinquish their right to live in the community, given reasonable accommodations, in order to receive needed services. States must strive to meet the ADA's mandates by continuing to develop high quality home and community-based services and supports for individuals with disabilities who need and desire such services and supports.
      3. States must adopt even-handed and equitable funding of a range of services and support options to address the needs and desires of persons with disabilities. Funding decisions regarding institutional-based and community-based programs must be even-handed and equitable and be based on what an individual needs and desires, consistent with the mandate that programs must be administered in the most integrated setting appropriate. The Supreme Court does not interpret the ADA as requiring states to phase out institutions. However, no longer will states be permitted to make funding decisions based on endeavors to keep their institutions fully populated by persons that states' own professionals believe can appropriately be served in the community.
      4. A state's obligation to provide services in the most integrated setting is unequivocal, but it is not boundless. The question is not whether services must be provided in the most integrated setting, but when. The Supreme Court recognizes:
        • The duty to provide community-based programs for those currently inappropriately placed in institutions is subject to the fundamental alteration defense, including the need to provide a degree of flexibility (with limits) to state policymakers in funding a range of programs of qualified individuals with disabilities, waiting lists moving at a reasonable pace and the development of a comprehensive, effectively working plan; and
        • The need to defer to the reasonable judgments of the state's professionals.
      5. Implications for the Medicaid program. The Olmstead decision is not about Medicaid, it is about discrimination under the ADA i.e., unjustified isolation and segregation in the delivery of medical services made available by the state.
        • The Court views Medicaid in terms of funding source for specified services, with recognition that recent changes in the Medicaid legislation express a preference for funding home and community-based programs.
        • States may apply for waivers or request increases in waiver slots, or fill slots or they can fund community-based programs using state or local funds. These are decisions for state and local policy makers.
  2. FACTS OF THE CASE
    1. L.C. and E. W. are mentally retarded women.
    2. L.C. also has been diagnosed with schizophrenia and E.W. with a personality disorder.
    3. L.C. was voluntarily admitted to Georgia Regional Hospital where she was confined for treatment in a psychiatric unit.
    4. Her treatment team agreed that her needs could be met appropriately in one of the community-based programs the state supported.
    5. Despite this evaluation she remained institutionalized for 3 years before the state finally placed her in a community-based program.
    6. E.W. was voluntarily admitted to the GRH where she was confined for treatment in a psychiatric unit. The state sought to discharge her to a homeless shelter, but abandoned that plan when her attorney protested.
    7. Her treating psychiatrist concluded that she could be treated appropriately in a community-based setting.
    8. She nonetheless remained institutionalized until a few months after the district court handed down its decision.
    9. L.C. and E.W. alleged that the proscription of discrimination under title II of the ADA requires placement in community settings rather than institutions.
  3. POSTURE OF THE CASE
    1. The District Court granted partial summary judgment in favor of L.C. and E.W. The district court rejected the state's argument that inadequate funding, not discrimination accounted for their retention in the institution. The District Court concluded, "unnecessary institutional segregation of the disabled constitutes discrimination per se, which cannot be justified by a lack of funding."
    2. The Court of Appeals for the 11th Circuit affirmed the judgment of the District Court but remanded the case for reassessment of the state's cost-based defense. The Court of Appeals recognized that the state's duty to provide integrated services is not absolute. The Court of Appeals concluded, however, that Congress wanted to permit a cost defense only in the most limited of circumstances. The standard used by the court was that a cost justification would fail unless the state can prove that requiring it to expend additional funds in order to provide L.C. and E.W. with integrated services would be so unreasonable given the demands of the state's mental health budget that it would fundamentally alter the services the state provides.
    3. The Court of Appeals remanded the case to the district court to consider, among other things, whether the additional expenditures necessary to treat L.C. and E.W. in community-based settings would be unreasonable given the demands of the state's mental health budget.
  4. ISSUE BEFORE THE SUPREME COURT
    1. Whether the proscription of discrimination may require placement of persons with mental disabilities in community settings rather than in institutions?
  5. HOLDING (JUNE 22, 1999)
    The answer is a qualified yes. Such action is in order when:
    • The state's treatment professionals have determined that community placement is appropriate;
    • The transfer from institutional care to a less restrictive setting is not opposed by the affected individual; and
    • The placement can be reasonably accommodated, taking into account the resources available to the state and the needs of others with mental disabilities.

    The Court remanded the case for further consideration of appropriate relief given the 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. In other words, unjustified isolation is properly regarded as discrimination based on disability. But the Court also recognized the state's need to maintain a range of facilities for the care and treatment of persons with diverse mental disabilities and the state's obligation to administer services with an even hand. Accordingly, the Supreme Court held that the Court of Appeals remand instructions were unduly restrictive.

    In evaluating the state's fundamental alteration defense, the District Court must consider, in view of the resources available to the state not only the cost of providing community-based services care to the litigants but also the range of services the state provides others with mental disabilities and the state's obligation to mete out those services equitably.

    The Supreme Court affirmed the judgment of the Court of Appeals in part and vacated the judgment in part and remanded the case for further proceedings consistent with its opinion.

  6. POSITIONS TAKEN BY JUSTICES
    1. Justice Ginsburg announced the opinion of the Court. Joining Justice Ginsburg in the majority decision were Justices Stevens, O'Connor, Souter and Breyer, although Breyer stated in a concurring decisions that he would simply have affirmed the judgment of the Court of Appeals and therefore did not sign on to the portion of the decision that vacated a portion of the Court of Appeal's ruling and remand.
    2. A separate opinion written by Justice Kennedy and joined by Justice Breyer concurred in only part of the decision. Justices Kennedy and Breyer would have remanded the case for a ruling on whether discrimination actually occurred. Leaving open the possibility rejected in the dissent that discrimination "could" occur, but rejecting the conclusion that it had been proved already.
    3. A dissent written by Justice Thomas and joined by Chief Justice Rehnquist and Justice Scalia disagreed with the majority's definition of discrimination.
  7. THE APPLICABLE LEGAL FRAMEWORK
    1. Congressional statement of findings.
      • Historically, society has tended to isolate and segregate individuals with disabilities...
      • Discrimination...persists in such critical areas as institutionalization...
      • Individuals with disabilities continually encounter various forms of discrimination, including segregation
    2. Congressional statement of policy. The statute as a whole is intended to provide a "clear and comprehensive national mandate for the elimination of discrimination.
    3. Statutory language: The case involves title II, the public services portion of the ADA, which reads: "...No qualified individual with a disability shall, by reason of such disability, be excluded from participation in or be denied the benefits of the services, programs, or activities of a public entity, or be subjected to discrimination by any such entity."
    4. Regulations: Congress instructed the Attorney General to issue regulations implementing the provisions of title II and directed that the regulations be consistent with the coordination regulations applicable to recipients of federal aid under section 504 of the Rehabilitation Act.
    5. As instructed the AG issued regulations, including one modeled on the section 504 regulation called the "integration" regulation. The regulation reads: "A public entity shall administer services, programs, and activities in the most integrated setting appropriate to the needs of qualified individuals with disabilities."
    6. The preamble to the regulations defines the "most integrated setting appropriate to the needs of qualified individuals with disabilities to mean "a setting that enabled individuals with disabilities to interact with nondisabled persons to the fullest extent possible."
    7. Another regulation requires public entities to "make reasonable modifications" to avoid discrimination on the basis of disability "unless those modifications would fundamentally alter the nature of the service, program, or activity."
    8. In carrying out Congress' instructions to issue regulations, the AG made two key determinations.
      • First, the AG concluded that unjustified placement or retention of persons in institutions severely limits their exposure to the outside community and constitutes a form of discrimination prohibited by title II of the ADA.
      • Second, regarding the state's obligation to avoid unjustified isolation of individuals with disabilities, the AG provided that states could resist modifications that would fundamentally alter the nature of the service, program, or activity.
    9. Note: The Court simply restated the regulations without determining their validity.
  8. IN DEPTH ANALYSIS OF THE COURT'S HOLDING
    1. State's Arguments.
      The state argued that L.C. and E.W. encountered no discrimination "by reason of disability" because they were not denied community placement on account of those disabilities. Nor were they subjected to discrimination because discrimination necessarily requires uneven treatment of similarly situated individuals i.e., L.C. and E.W. had no comparison class.
    2. Court's Concept of Discrimination Under ADA Includes Unjustified Isolation and Segregation.
      1. The Court concluded that "we are satisfied that Congress had a more comprehensive view of the concept of discrimination advanced in the ADA."
      2. The Court recognized that unjustified isolation of persons with disabilities is a form of discrimination reflects two evident judgments.
        • Fist, institutional placements of persons who can handle and benefit from community settings perpetuates unwarranted assumptions that persons so isolated are incapable or unworthy of participating in community life.
        • 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.
      3. Dissimilar treatment correspondingly exists in this key respect: in order to receive needed medical services, persons with mental disabilities must, because of those disabilities, relinquish participation in community life they could enjoy given reasonable accommodations, while persons without mental disabilities can receive the medical services they need without similar sacrifice.
    3. Medicaid.
      The Supreme Court agreed with the state's assertion that Medicaid reflected (past tense) a bias toward institutionalization. However, the Court finds that since 1981, Medicaid has provided funding for state run home and community-based care through a waiver program. HHS has a policy of encouraging states to take advantage of the waiver program.
    4. General Discussion of What Is and Is Not Required by the ADA.
      1. Nothing in the ADA or its implementing regulations condones termination of institutional settings for persons unable to handle or benefit from community settings.
      2. States may rely on the reasonable assessments of its own professionals in determining whether an individual meets the essential eligibility requirements for community-based programs (most integrated setting appropriate). Citing to Arline for the proposition that courts normally should defer to the reasonable medical judgments of public health officials.
      3. There is no federal requirement that community-based treatment is imposed on patients who do not desire it. Persons with disabilities must be provided with the option of declining to accept a particular accommodation.
      4. The ADA is not reasonably read to impel states to phase out institutions, placing patients in need of close care at risk.
      5. The ADA's mission is not to drive states to move institutionalized patients into an appropriate setting such as a homeless shelter, a placement the state proposed and than retracted for E.W.
      6. The Decision cites to a brief prepared by the Voice of the Retarded (VOR) with approval for the proposition that each disabled person is entitled to treatment in the most integrated setting possile for that person-recognizing that, on a case-by-case basis, that setting may be in an institution.
    5. Scope of States' Responsibilities Under the Reasonable Modifications/Fundamental Alteration Provisions.
      1. The state's responsibility once it provides community-based treatment to qualified persons with disabilities is not boundless. The regulations speak of "reasonable modifications and allows state's to resist modifications that entail a fundamental alteration.
      2. The Court of Appeals construction of the reasonable modification regulation is unacceptable for it would leave the state virtually defenseless once it is shown that the plaintiff is qualified for the service or program she seeks. If the expense entailed in placing one or two people in a community based treatment program is properly measured for reasonableness against the state's entire mental health budget, it is unlikely that a state relying on the fundamental alteration defense could ever prevail.
      3. Sensibly construed, the fundamental alteration component of the reasonable modification regulation would allow the state to show that in the allocation of available resources, immediate relief for the plaintiffs would be inequitable given the responsibility the state has undertaken for the care and treatment of a large and diverse population of persons with mental disabilities.
      4. A simple comparison between the cost of caring for the plaintiffs in a community-based setting with the cost of caring for them in an institution may overlook cost the state cannot avoid-a state may experience increased overall expenses by funding community placements without being able to take advantage of the savings associated with the closure of institutions.
      5. To maintain a range of facilities and to administer services with an even hand the state must have more leeway than the courts below understood the fundamental alteration defense to allow. For example, if the state were to demonstrate that it had a COMPREHENSIVE, EFFECTIVELY WORKING PLAN, for placing qualified persons with mental 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. In such circumstances, a court would have no warrant effectively to order displacement of persons at the top of the community-based treatment waiting list by individuals lower down who commenced civil action.
  9. CONCURRING OPINION (Justice Stevens, concurring in part and concurring in the judgment).
    1. Unjustified institutional isolation constitutes discrimination under the ADA.
    2. State may assert as an affirmative defense "fundamental alteration."
    3. Believe Supreme Court should have simply affirmed the decision of the Court of Appeals.
  10. CONCURRING OPINION (Justice Kennedy, with whom Justice Breyer joins as to Part I, concurring in the judgment)
    1. It would be a tragic event were the ADA to be interpreted so that states had some incentive, for fear of litigation, to drive those in need of medical care and treatment out of appropriate care [provided in institutions] and into settings with too little assistance and supervision.
    2. The opinion of a responsible treating physician in determining the appropriate conditions for treatment ought to be given the greatest of deference.
    3. If the principle of liability enunciated by the Court is not applied with caution and circumspection, states may be pressured into attempting compliance on the cheap, placing marginal patients into integrated settings devoid of the services and attention necessary for their condition.
    4. Courts must apply today's decision with great deference to the medical decisions of the responsible treating physicians and the Court makes clear, with appropriate deference to the program funding decisions of state policymakers.
    5. Theory for finding discrimination against similarly situated individuals. Plaintiffs would have to show that the state:
      • Provides treatment to individuals suffering from medical problems of comparable seriousness;
      • As a general matter, does so in the most integrated setting appropriate for the treatment of those problems (taking medical and other practical considerations into account) but
      • Without adequate justification, fails to do so for a group of mentally disabled persons (treating them instead in separate, locked institutional facilities).
    6. Of course, it is quite a different matter to say that a state without a program in place is required to create one. Grave constitutional concerns are raised when a federal court is given the authority to review the state's choices in basic matters such as establishing or declining to establish new programs. It follows that a state may not be forced to create a community treatment program where none exists (citing to the Justice Department brief at page 19-20, note 3.
    7. The ADA does not necessitate a regime in which individual treatment plans are required, as distinguished from broad and reasonable classifications for the provision of health care services.
    8. The state is entitled to wide discretion in adopting its own systems of cost analysis and, if it chooses, to allocate health care resources based on fixed and overhead costs of whole institutions and programs. We must be cautious when we seek to infer specific rules limiting state choices when Congress has used only general language in the controlling statute.
  11. DISSENTING OPINION (Thomas, Rehnquist and Scalia)
    1. Temporary exclusion from community placement does not amount to discrimination.
    2. Until today, this Court has never endorsed an interpretation of the term discrimination that encompassed disparate treatment among members of the same protected class.
    3. Type of claim approved by the majority does not concern a prohibition against certain conduct (the traditional understanding of discrimination) but rather imposition of a standard of care.
    4. Concern that majority opinion imposes significant federalism costs, directing states how to make decisions about their delivery of public services.
    5. The majority's affirmative defense will likely come as cold comfort to the states that will now be forced to defend themselves in federal court every time resources prevent the immediate placement of a qualified individual.
    6. No discrimination by reason of disability. Community placement simply is not available to those without disabilities.
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