Court Opinion

ID: 9496032
Source: CourtListenerOpinion
Date Created: 2023-08-05 16:16:23.133656+00
Date Added: 2024-06-11T17:57:20.051062
License: Public Domain

BEEZER, Circuit Judge,
dissenting:
Levi Townsend contends that the Americans with Disabilities Act requires Washington to create a home and community care program for disabled Medicaid recipients who fall into Medicaid’s “medically needy” category. Because the comprehensive structure of the Medicaid Act forecloses this result, Townsend’s claim under the Americans with Disabilities Act should fail. The court’s opinion to the contrary fails to accord sufficient weight to the Medicaid Act’s statutory scheme.
I respectfully dissent.
*521I
The Medicaid Act recognizes three broad categories of services that states may use to provide long term medical care to eligible Medicaid recipients. These three service categories are defined by federal law and are defined with reference to where an eligible recipient resides and receives care.
The first category of services are “nursing facility services” (“nursing home care”), which involve medical services provided to Medicaid recipients whose needs require institutionalization in nursing homes.1 At a minimum, states must provide nursing home care to the neediest Medicaid recipients, those who are classified as “categorically needy.”2 States have the option of providing nursing home care to less needy Medicaid recipients who fall into the “medically needy” category.3
The second category of services are “home and community-based services” (“community care”), which involve a wide range of medical services provided to Medicaid recipients who would otherwise require care in a nursing facility.4 These medical services allow recipients to remain living in their personal residence or other housing in their community. Included within the scope of community care are such services as:
(1) case management services;
(2) homemaker services;
(3) home health aide services;
(4) personal care services;
(5) adult day services;
(6) habilitation services; and
(7) respite care services.5
The Medicaid Act gives states the option of offering community care to Medicaid recipients.6 In an effort to encourage states to offer community care to the disabled, Congress has established a waiver program.7
The waiver program exempts states from certain Medicaid requirements for federally-approved community care programs.8 The waiver program allows states to offer community care to identified subgroups of Medicaid recipients.9 The dis*522abled constitute one of these subgroups.10
Although states are encouraged to create community care programs for the disabled, there is one significant limitation on their ability to create such programs. States cannot create community care programs for the disabled without prior approval from the federal government.11
The third category of long term care recognized by the Medicaid Act involves “home health services” (“home care”).12 These services are generally provided in a residential setting, but like community care, home care allows recipients to remain in their communities and avoid institutionalization.13 At a minimum, a state’s home care program must include: (1) nursing services, (2) home health aid services and (3) medical supplies, equipment and appliances.14
Under most circumstances, the creation of home care programs falls to the discretion of the states.15 If a state provides nursing home care to recipients in a given Medicaid category, however, it must also provide home care to recipients in that category.16
The state of Washington provides Medicaid recipients who fall into the categorically needy classification with for nursing home care, community care and home care.17 Washington provides the medically needy with nursing home care and home care.18 Washington state does not provide community care for the medically needy.19
II
Townsend argues that it is discriminatory for Washington to offer him nursing home care without also offering him community care. He relies on the Americans with Disabilities Act and one of its implementing regulations, 28 C.F.R. § 35.180(d), in support of his argument that Washington discriminates on the basis of disability. This argument ultimately fails because it does not adequately account for the interaction between the Americans with Disabilities Act and the Medicaid Act.
A
Title II of the Americans with Disabilities Act provides that “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.” 42 U.S.C. § 12132. Under the Department of Justice regulations implementing the Americans with Disabilities Act, public entities like the State of Washington are required to:
make reasonable modifications in policies, practices or procedures when the modifications are necessary to avoid discrimination on the basis of disability, unless the public entity can demonstrate *523that making the modifications would fundamentally alter the nature of the service, program or activity.20
Townsend relies on another section of the same Department of Justice regulation in support of his argument that Washington discriminates against him.21 Section 35.130(d) (“the integration mandate”) requires public entities “to administer services, programs and activities in the most integrated setting appropriate to the needs of qualified individuals with a disability.”22 The most integrated setting is “a setting that enables individuals with disabilities to interact with nondisabled persons to the fullest extent possible.”23 A failure to comply with § 35.130(d) would constitute discrimination because Congress explicitly recognizes that the “segregation” of persons with disabilities is a form of discrimination.24
B
Townsend contends that Washington violates the integration mandate. He first argues that he is eligible to receive the medical services he needs under Washington’s Medicaid program if he submits to institutionalization, the prerequisite for receiving nursing home care. He then argues that Washington could, if it so chose, allow him to receive the same medical services he needs in a less isolated setting by establishing a community care program.
According to Townsend, because Washington could provide him with the services he needs in a home or community setting, forcing him to receive these services in a nursing home violates the integration mandate. He therefore believes that Washington must create a community care program for the disabled who fall within the medically needy category.
The state of Washington counters that the Medicaid Act does not require it to provide community care to anyone within the medically needy category. The state further contends that it would be unreasonable and a fundamental alteration of its Medicaid program to require the state to create an entirely new community care program for medically needy disabled individuals like Townsend.
Townsend’s claim under the Americans with Disabilities Act should not succeed. It is necessary to address the interaction between the Medicaid Act and the Americans with Disabilities Act to see why Townsend’s claim fails. A proper reconciliation of these two statutes leads to the conclusion that Washington is not required by the Americans with Disabilities Act to provide community care coverage for disabled Medicaid recipients who fall into the medically needy classification.
C
Whenever two federal statutes may be in tension or conflict, we are required to reconcile the two statutes. The Supreme Court has given us instructions on how to do so:
It is a basic principle of statutory construction that a statute dealing with a narrow, precise, and specific subject is not submerged by a later enacted statute covering a more generalized spectrum, unless the latter statute expressly contradicts the original act or unless *524such a construction is absolutely necessary in order that the words for the later statute shall have any meaning at all. The courts are not at liberty to pick and choose among congressional enactments, and when two statutes are capable of co-existence, it is the duty of the courts, absent a clearly expressed congressional intention to the contrary, to regard each as effective.25
Applying these instructions, we should conclude that Title II of the Americans with Disabilities Act cannot require Washington to offer community care for disabled medically needy Medicaid recipients.
D
The Medicaid Act establishes a comprehensive framework regulating the Medicaid program. It is a narrow statute that informs states about what medical services must be provided and what medical services are optional. The Medicaid Act also establishes procedural rules governing the provision of these services. Because the Medicaid Act is a narrow, comprehensive statute, we must apply the Traynor analysis in evaluating the impact of the Americans with Disabilities Act on the Medicaid Act.26
The Medicaid Act leaves the creation of community care programs to the broad discretion of the states.27 The only significant limitation on this discretion is that states are forbidden from creating community care programs for the disabled without prior federal approval.28 There is no statute or regulation that requires states to create community care programs. Community care is the only form of long term care that the Medicaid Act does not require under any set of circumstances.29 A requirement that states provide community care programs to the disabled is inconsistent with the Medicaid Act’s text and structure.
Moreover, Congress consciously chose not to link community care for the disabled to the provision of nursing home care.30 In the same legislation that established the community care waiver program, Congress made the coverage of home care mandatory for any Medicaid group that receives coverage for nursing home care.31 At that time Congress opted merely to encourage the creation of community care programs *525and to do so without regard to the existence or non-existence of nursing home care programs.32 Congress has not seen fit to replace the waiver program with a mandatory requirement over the course of the last two decades, leaving the waiver program’s optional approach to community care programs for the disabled in force.
Applying Tmynor, the Americans with Disabilities Act should not transform Washington’s exercise of congressionally-conferred discretion into discrimination. The court’s opinion to the contrary effectively submerges several sections of the Medicaid Act under the perceived force of the integration mandate. Today’s opinion casts aside the conscious choices Congress made in permitting, but not requiring, states to provide community care for the benefit of the disabled. Under Tmynor this result is to be avoided if an alternate approach would continue to give effect to both the Americans with Disabilities Act and the Medicaid Act.33 Recognizing that the Americans with Disabilities Act does not address the state of Washington’s initial decision whether or not to create a community care program provides just such an alternate approach. Recognizing limits on the ADA in the community care context still leaves the ADA with significant force in regulating the provision of community care to the disabled. Once a state decides to offer community care to a given Medicaid category, states must administer their community care waiver programs in a manner that complies with the integration mandate.34 Following Tray-nor’s requirement that we adopt the interpretation that gives a narrow statute like the Medicaid Act full meaning, I would conclude that the ADA does not address Washington’s discretion in creating community care programs as the Medicaid Act provides the governing principles.
Because the Americans with Disabilities Act simply does not reach the question posed in this case, the state of Washington’s refusal to create a community care program for medically needy disabled recipients is not discrimination based on disability. The state need not entertain Townsend’s proposed modification to its Medicaid program because no modification is needed to “avoid discrimination based on disability.”35
E
Looked at another way, even if Washington’s failure to create a community care program for the medically disabled could be considered discriminatory, Townsend’s proposal, which requires the creation of a community care program, would not be a reasonable modification. Congress has chosen not to require states to create community programs and Townsend’s desire cannot justify setting that choice aside.
The Supreme Court in U.S. Airways v. Barnett, 535 U.S. 391, 122 S.Ct. 1516, 1523, 152 L.Ed.2d 589 (2002), recognized in the employment context that Title I of the Americans with Disabilities Act, 42 U.S.C. §§ 12111-17, does not require an employer to provide an accommodation, even if the accommodation would enable an employee to perform a given task, *526where the accommodation is not independently reasonable.36 Barnett holds that a privately imposed seniority system may trump an employee’s proposed accommodation because “it would not be reasonable in the run of cases that the assignment in question trump the rules of a seniority system.”37 I fail to see how Townsend’s attempt to set aside the congressional decisions vesting states with discretion in creating community care programs and refusing to link community care for the disabled with the provision of nursing home care can be considered “reasonable.”
Ill
The opinion of the court filed today relies heavily on the Supreme Court’s decision in Olmstead v. L.C., 527 U.S. 581, 119 S.Ct. 2176, 144 L.Ed.2d 540 (1999), in seeking to justify the conclusion that Townsend’s proposed modification is reasonable.38 Olmstead does not compel today’s decision, but instead supports the conclusion that the Americans with Disabilities Act does not reach Washington’s conduct in this case.
Although there is isolated language in Olmstead that might suggest that the Americans with Disabilities Act’s findings regarding segregation bring a state’s discretion in creating community care programs into question, see 527 U.S. at 599-GOO, 119 S.Ct. 2176,39 the plurality portion of Justice Ginsburg’s opinion explicitly cabined Olmstead’s reach. Justice Ginsburg’s opinion recognized that the “State’s responsibility, once it provides community-hased treatment to qualified persons with disabilities, is not boundless.”40
The majority portion of Justice Ginsburg’s opinion even appears to address the very question posed by this case.41 In footnote 14, the Olmstead court states:
We do not ... hold that the Americans with Disabilities Act ... requires States to ‘provide a certain level of benefits to individuals with disabilities.’ We do hold, however, that States must adhere to the Americans with Disabilities Act’s nondiscrimination requirement with regard to the services they in fact provide.42
Justice Kennedy’s concurrence is even more clear on this point: “a State may not be forced to create a community-based treatment program where none exists.”43 Cumulatively, these indications in Olm-stead favor recognizing the states’ continu*527ing discretion in creating community care programs, not drastically restricting it.44
The court’s opinion misses these indicators, drawing from Olmstead only the lesson that “where the issue is location of services, not whether services will be provided, Olmstead controls.” What the court’s opinion fails to recognize is that this case, unlike Olmstead, involves the question whether Washington must provide disabled medically needy Medicaid recipients with a specific set of new services, namely community care.
Today’s opinion evades this question by defining the relevant services as “long term care.” This ignores the fact that the services involved in Olmstead and this case are defined by federal law with reference to their location.45 Federal law further recognizes nursing home care and community care as distinct services.46 The federal source of these definitions prevents the possibility, raised in the court’s opinion, that states will attempt to manipulate the definition of services to exclude the disabled.47 By redefining the services at issue at a broad level of generality, today’s opinion contravenes Traynor’s instruction to give effect to narrow, comprehensive statutes like the Medicaid Act and Alexander v. Choate, 469 U.S. 287, 303, 105 S.Ct. 712, 83 L.Ed.2d 661 (1985), which rejected the “notion that the benefit provided through state Medicaid programs” consists of amorphous objectives.48
Because Olmstead does not transform the state of Washington’s exercise of con-gressionally-conferred discretion into a discriminatory act, Townsend’s proposed modification fails as a matter of law.
IV
Townsend ultimately argues that a judgment directing Washington to accommodate him by providing community care to medically needy disabled individuals is reasonable. The claim of reasonableness is based on Townsend’s assertion that community care costs less than institutionalized treatment; that community care will meet the goals of Washington’s Medicaid program; and that he and like minded recipients will receive great personal benefit from such a program.
The text and structure of the Medicaid Act nevertheless make these policy considerations secondary. Congress has decided to encourage the provision of community care without regard to whether a state provides nursing home care, rather than requiring universal delivery of community care to the disabled. I would affirm the district court because Townsend’s proposal to the contrary is not “reasonable” as a matter of law.
*528Townsend’s desire to utilize home and community-based services to remain in the community is both understandable and reasonable. Despite this, federal law does not require the state of Washington to fulfill Townsend’s desire.

. See 42 U.S.C. §§ 1396a(a)(10)(A), 1396d(a)(4), (f), 1396r; 42 C.F.R. § 440.155(a).

. See 42 U.S.C. §§ 1396a(a)(10)(A), 1396d(a)(4); Skandalis v. Rowe, 14 F.3d 173, 175 (2d Cir.1994).

. See 42 C.F.R. § 440.225 (recognizing that the provision of services other than those listed in 42 C.F.R. §§ 440.210 and 440.220 is optional); Skandalis, 14 F.3d at 175-76 (explaining the distinction between the "categorically needy” and the "medically needy”).

. See 42 U.S.C. § 1396n(c); 42 C.F.R. §§ 440.180, 441.300-.310.

. 42 C.F.R. § 440.180.

. See 42 U.S.C. § 1396a(a) (outlining the Medicaid Act's mandatory requirements); Beal v. Doe, 432 U.S. 438, 444, 97 S.Ct. 2366, 53 L.Ed.2d 464 (1977) (recognizing the "broad discretion" conferred by the Medicaid Act on the states in determining the extent of medical assistance); see also 42 C.F.R. §§ 440.210 (listing required services for the categorically needy), 440.220 (listing required services for the medically needy), 440.225 (recognizing that all other services "may be furnished under the State plan at the State's option”).

. See 42 U.S.C. § 1396n(c); 42 C.F.R. § 430.25; see also Olmstead v. L.C., 527 U.S. 581, 601, 119 S.Ct. 2176, 144 L.Ed.2d 540 (1999) (recognizing the Department of Health and Human Services policy of "encouraging States to take advantage of the waiver program”).

. See 42 U.S.C. § 1396n(c)(3).

. See 42 U.S.C. § 1396n(c); 42 C.F.R. § 441.301(b)(6).

. 42 C.F.R. § 441.301(b)(6).

. See 42 U.S.C. § 1396n(c); 42 C.F.R. § 441.300; Skandalis, 14F.3datl76.

. See 42 U.S.C. § 1396a(a)(10)(D), 1396d(a)(7); 42 C.F.R. § 440.70.

. See 42 C.F.R. § 440.70; see also Skubel v. Fuoroli, 113 F.3d 330, 337 (2d Cir.1997) (holding that § 440.70’s in-home limitation is unreasonable).

.42 C.F.R. § 440.70.

. See 42 C.F.R. § 440.225.

. 42 U.S.C. § 1396a(a)(10)(D).

. See Wash. Admin. Code §§ 388-513-1301; 388-529-0200.

. See Wash. Admin. Code § 388-529-0200.

. See Wash. Admin. Code § 388-529-0200.

. 28 C.F.R. § 35.130(b)(7).

. See 28 C.F.R. § 35.130(d).

. Id.

. 28 C.F.R. Pt. 35, App. A.

. See 42 U.S.C. § 12101(a)(2), (5); see also Olmstead v. L.C., 527 U.S. 581, 600, 119 S.Ct. 2176, 144 L.Ed.2d 540 (1999).

. Traynor v. Turnage, 485 U.S. 535, 547-48, 108 S.Ct. 1372, 99 L.Ed.2d 618 (1988) (internal citations, brackets and quotation marks omitted).

. See Traynor, 485 U.S. at 547-48, 108 S.Ct. 1372 (recognizing that principles for reconciling a statute addressing a narrow, precise and specific subject with more generalized legislation).

. See 42 C.F.R. § 440.225.

. See 42 U.S.C. § 1396n(c); 42 C.F.R. §§ 430.25, 441.300; Skandalis, 14 F.3d at 176.

. Cf. 42 U.S.C. §§ 1396(a)(10)(A) (requiring nursing home care for the categorically needy), 1396(a)(10)(D) (requiring home care for those Medicaid categories that receive nursing care).

. Cf. TRW, Inc. v. Andrews, 534 U.S. 19, 31 n. 5, 122 S.Ct. 441, 151 L.Ed.2d 339 ("we read Congress' codification of one judge-made doctrine not as a license to imply others, but rather as an intentional rejection of those it did not codify”); United States v. Fausto, 484 U.S. 439, 447, 108 S.Ct. 668, 98 L.Ed.2d 830 (1988) (relying on a statute’s comprehensive nature, the statute's attention to the category in question, and the exclusion of the category in question from one section of the statute to conclude that the exclusion represents an intentional "congressional judgment”).

. See Omnibus Budget Reconciliation Act of 1981, Pub.L. No. 97-35 §§ 2171, 2176, 95 Stat. 807-08, 812-13 (codified at 42 U.S.C. §§ 1396a(a)(10)(D), 1396n(c)).

.See Omnibus Reconciliation Act of 1981, Pub.L. No. 97-35 § 2176, 95 Stat. 812-13; see also Pennhurst State School & Hosp. v. Halderman, 451 U.S. 1, 27, 101 S.Ct. 1531, 67 L.Ed.2d 694 (1981) (recognizing the "well-settled distinction between 'encouragement' of state programs and the imposition of binding obligations on the States”).

. See 485 U.S. at 547-48, 108 S.Ct. 1372.

. See Olmstead, 527 U.S. at 603, 607 & n. 14, 119 S.Ct. 2176.

. 28 C.F.R. § 35.130(b)(7).

. The "reasonable” requirement is effectively equivalent for purposes of Title I and Title II of the ADA. See School Board of Nassau County v. Arline, 480 U.S. 273, 287 n. 17, 107 S.Ct. 1123, 94 L.Ed.2d 307 (1987); Vinson v. Thomas, 288 F.3d 1145, 1154 (9th Cir.2002).

. Barnett, 122 S.Ct. at 1524.

. Today’s reliance on the integration mandate is also misplaced. The court's opinion fails to indicate how the ADA's version of the integration mandate can require the provision of community care programs for the disabled when Congress created the waiver program in the face of cognate regulations imposing an integration mandate on the Department of Health and Human Services. See 45 C.F.R. § 84.4 (1981); 42 Fed.Reg. 22677, 22679 (1977); see also 28 C.F.R. § 41.51(d) (1981); Olmstead, 527 U.S. at 592, 119 S.Ct. 2176.

. But see Pennhurst State School & Hosp. v. Halderman, 451 U.S. 1, 19, 101 S.Ct. 1531, 67 L.Ed.2d 694 (1981) (holding a general statement of findings was "too thin a reed to support the rights and obligations read into it by the court below").

. Olmstead, 527 U.S. at 603, 119 S.Ct. 2176 (emphasis added).

. See Olmstead, 527 U.S. at 603 n. 14, 119 S.Ct. 2176.

. Id. (emphasis in original).

. Id. at 612-13, 119 S.Ct. 2176 (Kennedy, J„ concurring).

. It should be noted that Olmstead involved a situation where the state already had a community care program for which the plaintiffs were qualified. See 527 U.S. at 593, 601, 119 S.Ct. 2176. In Olmstead the state was simply not moving the plaintiffs into the program. 527 U.S. at 601, 119 S.Ct. 2176 (recognizing that Georgia had over 1400 unused waiver slots by 1996). This is a far cry from the situation here.

. See 42 U.S.C. §§ 1396d(f), 1396n(c)(l); 42 C.F.R. § 440.180.

. See 42 U.S.C. §§ 1396d(f), 1396n(c).

. In contrast to the court’s opinion, I see no reason to fault states like Washington for adopting the very definitions found in the Medicaid Act. See Harris v. McRae, 448 U.S. 297, 301, 100 S.Ct. 2671 (1980) (states must comply with the Medicaid Act’s requirements if they elect to participate in the program).

. Alexander explicitly recognizes that "the benefit provided remains the individual services offered." 469 U.S. at 303, 105 S.Ct. 712 (emphasis added).