question of who has the obligation to provide care and i think at the bottom line there's the obvious that it's all well and good too to order a public entity to keep a hospital open or to provide care but it can't be separated from the fact that there has to a provider has a requirement under medicaid to assure a particular level of services of adequate services and it has meaning out when you look at the medicaid system that is an obligation that the state has even the other during a period of time one of the things or until care comparable care was provided at other hospitals including private hospitals in calgary in the local los angeles area and that's not something that the county of los angeles can control because we talking about with this court granting relief under the medicaid act here and it's incorporated in the injunction itself is that notion that we have to provide services comparable to those that we provided to private patients in the private sector and that is in the language of the injunction question that the medicaid provisions do put restrictions requirements on providers and the county is by and as a judicially enforceable obligation and this court under federal law it could be i'm not sure wh well i think it's the provider obligations i think the most specific one that we've even had a briefing on here are the ones that have gotten more play in the in the harris case for example just charge planning for those in patient that meet the criteria where they need discharge planning it's a very specific regulation but that's not the source of this injunction and it's not in the language of the injunction here in iraq about what level of what level of care is the county required to how you'll be able to close when they talk it's just part of the general level of services rehabilitation services that the whole panoply of services offered by rancho under the medicaid actually you have to keep providing them until you can show that somebody in the private sector i doing that and i think you know we're talking about the level of care i think again it's switching the hat that the county where isn't the only had it can we under the medicaid act which is as a provider not as someone who's administering the program that has to make sure administrator of the program and i think that's again because it's the states that have that obligation not the providers and bear in mind again the county is a public entity medicaid provide right you practice that you have no minimum requirement of we talk about them you know in the briefing terms of the mandatory the amount of funding that you have to have to attract people from the private sector i mean i think it's the listing apples with oranges that providers are different than the states administrators in the system is geared towards the state as administrator in fact i think we even know that one of the things they didn't want the states to do was to try and delegate this responsibility to somebody else and i think that's really what we have going on here which is the medicaid providers but again there's nothing unique to the county about being a medicaid provider i mean or if you want to do medicaid system and have private hiders leave believe me a case that holds that if you sign on as a provider you have to guarantee a level of services that looks the same as the private sector and offer those whether it's financially feasible for you to do so no one is going to participate in this program well the level of the private sector are they talking about them on reasonable medical services that are talking about which sport you know you would get it at some unbelievably there but that that's kind of what is happening here which is we're being told you offer these services you have to offer the full panoply of services whether or not you can or not whether it's financially feasible for you to do or not and i submit again you look at the  not have an effect on somebody who won't get the same benefit as any other patient because the individual circumstances are so different from patient to patient so you look at the general benefit and you simply don't ask is that going to have a different impact because this person needs more care you just asked is that a benefit available across the board and here i mean i think it's telling the district court's order itself it talks about the medicaid benefit as the benefit is adequate medical care and that is expressed in what the supreme court repudiated in alexander because you have that paralysis that sets in because the people running the medicaid program you know provider what have you on the front lines doing this have no means to make decisions on particular care they want to impact somebody he'll say well gee i'm just not getting the same benefit as somebody else and i mean the course language on this couldn't be any more contrary to what alexander was talking about because it doesn't ask let me ask you this and i'm i'm sharpening the fact that you're not going to find a description of the facts let's say you got six hospitals in the county only one of which provides comprehensive services to the to the disabled and the state in an why because those individuals could come to either county facilities to receive other types of get to receive acute care or things of that but what happens with the national line at this time of the other hospitals are equipped to do that people with different disabilities not with especially if you try to get a ranch out you have both of those and that's the problem the alexander talks about you can't sit there between these two because it isn't just the disabled as a class it use exam we come here you want a flu shot everyone else you get a flu shot no complications you get a flu shot you need special go to class maybe even patient care or something else i think under those circumstances the benefit is everybody gets a flu shot if you need a flu shot long is we going to be a man and for the actual service provided i'll give you fourteen days of service that actually is a good service to somebody who's disabled you know you may need a little longer but at least i'm going to live during the fourteen days you're in the hospital i'm going to give you the service names actually introduce suitable for somebody health care may be to queue care and acute care hospital and what they're talking about and i know the court is you know there's no this is a hypothetical right and that's not the reality of the magic of medical care is people come in for all sorts of ma what what what what did you work this out in advance over who are you type typically treated at mantua will be excluded from and deny the benefits of the county's medical services or the medical services that we're talking about the district court was talking about are first of all essential in many cases quite literally to keep these people alive and in all cases to give them some semblance of a life but moreover the medical services that we're talking of included those which meaningful access to the medical treatment otherwise provided by the county people without such disabilities and the district court the factual record in that regard is summarized in the district court opinion pages six and seven pediatric care now those are all medical services that the county does not provide and will continue to provide for the people without disabilities at other facilities in the county and as dr white the chief of the only county hospital that does and can provide medical treatment of all kinds to people with severe disabilities and as the district court correctly found a note that's in a historical context factual record here will not receive the necessary essential medical services including services of the type the county will continue to provide to others at other locations this is very much in this respect like a the county has had an additional almost seven months since the p i was entered to go back to the district court and now make that show and they have failed to do so they have and of course as the record shows position he can hand that the obligation of the county as provider is narrower than the obligation of the state in a general an abstract sense do you agree that that's right as a general abstract sense in terms of providers as a general category i would say that's true ok why in this circumstance does the provider have an elevated the argument is in this circumstance the county has provider owes more or provider had has received or does receive especially given the county's billion dollar medicaid waiver demonstration project for which it agreed to heighten standards of care it is operating in state law contract is that federal medicaid law was the nature of that law i believe that the obligation comes from two places i believe that does come from state contract law because the county contract to do it but i think it also comes notation to that special funding that the county is often truthful in that area injunctions the real legal forded was tailored as narrowly as possible while still preventing the threatened harm and accordingly directed only at the party necessary to obtain the relief that was minimally adequate necessary medical care some minimally minimal special accommodation to people with disabilities that must be made i think did not find that there were any violations by the state and in fact it did not address whether there were any specific violations by the state any issue as to whether there were violations by the state is not proper for this appeal there was no appeal taken with respect to the court fact that this is a great a cut and what the record appears to be people who have a sense of circumstantial needs it's not a cut of everyone receiving care is cut ten percent well but let me tell you i mean they