Bumpus v. Clark

• Decision Date: 16 July 1982
• Docket Number: No. 77-2883,77-2883
• Parties: Alta BUMPUS, et al., Plaintiffs-Appellants, v. Donald E. CLARK, et al., Defendants-Appellees.
• Court: U.S. Court of Appeals — Ninth Circuit

Page 679

681 F.2d 679

Alta BUMPUS, et al., Plaintiffs-Appellants, v. Donald E. CLARK, et al., Defendants-Appellees.

No. 77-2883.

United States Court of Appeals, Ninth Circuit.

Argued and Submitted March 6, 1980.

Reassigned May 10, 1982.

Decided July 16, 1982.

Michael H. Marcus, Portland, Or., for plaintiffs-appellants.

John B. Leahy, Portland, Or., for defendants-appellees.

Appeal from the United States District Court for the District of Oregon.

Before HUG, FLETCHER and FARRIS, Circuit Judges.

FARRIS, Circuit Judge:

Plaintiffs are a class of elderly and disabled residents of Edgefield Manor, a nursing home owned and operated by Multnomah County, Oregon and licensed by the State as a Title XIX Intermediate Care Facility. Defendants are Multnomah County, the Multnomah County Board of Commissioners, the Department of Human Resources of the State of Oregon, and several directors and administrators of various state agencies responsible for supervising the provision of medical assistance under Title XIX. The dispute between the parties arises out of an announcement by Multnomah County that it is considering closing Edgefield Manor. Plaintiffs contend that closure of Edgefield Manor would be contrary to their rights under Title XIX, the United States Constitution, and the common law of Oregon. Plaintiffs seek declaratory

and injunctive relief preventing involuntary transfers and destruction of interpersonal relationships among residents and between residents and staff, or, in the alternative if closure is to be allowed, compelling a reasonably prompt decision regarding the future of Edgefield Manor and requiring that each resident be given notice and an evidentiary hearing prior to any transfer. The district court dismissed plaintiffs' federal claims under Fed.R.Civ.P. 12(b)(6). The district court then dismissed plaintiffs' federal claims under Fed.R.Civ.P. 12(b)(6). The district court then dismissed plaintiffs' pendent state law claims, citing United Mine Workers v. Gibbs, 383 U.S. 715, 725-27, 86 S.Ct. 1130, 1138-40, 16 L.Ed.2d 218 (1966). We affirm.

TITLE XIX

Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq., authorizes federal grants to the States to help pay for medical assistance for individuals whose income and resources are insufficient to meet the costs of necessary medical services. Federal assistance is available only to those States which adopt and adhere to an administrative plan for medical assistance satisfying the requirements set forth in § 1396a. The federal government has specified certain minimum categories of medical assistance which must be covered, but beyond that each State has discretion to adopt reasonable standards for determining how much medical assistance will be provided. See §§ 1396d(a), 1396a(a)(10), 1396a(a)(17). The overall goal of the Medicaid program is to enable each participating State to provide medical assistance "as far as practicable under the circumstances in such State." Section 1396.

The States generally do not provide the medical assistance directly. Instead, they enter into provider agreements with state-certified health care facilities that are willing to act as health care providers. Provider agreements are for a term of years, with near-automatic renewal unless the provider is decertified for failure to satisfy state requirements or voluntarily terminates the arrangement. This controversy arises out of the latter event; Multnomah County has decided to close Edgefield Manor and to withdraw as a Medicaid provider.

Plaintiffs contend the closure of Edgefield Manor would violate their rights under Title XIX. They argue that the County is obligated to continue to act as a provider. In the alternative, they argue that the State is obligated to step in and take over to preserve the status quo or, at the very least, to arrange for a collective transfer keeping the current group of residents and staff intact. We conclude that closure of Edgefield Manor would not violate plaintiffs' rights under Title XIX.

Plaintiffs have no claims against the County under Title XIX. Title XIX does not impose any obligations upon Medicaid providers. The providers are independent contractors whose only obligations under the Medicaid program arise out of their respective provider agreements. See Roberson v. Wood, 500 F.Supp. 854, 860 (S.D.Ill.1980):

Federal law and regulations nowhere provide that once a provider takes on patients, it can never withdraw from the program unless it is decertified by the government. Restrictions on the withdrawal of a provider can only possibly lie ... in the contract between the patients and the provider or in state law.

Title XIX does impose obligations on those States which choose to participate in the Medicaid program.

Plaintiffs' first argument against the State is that its failure to act to keep Edgefield Manor open constitutes a violation of plaintiffs' rights under section 1396a(a)(23) to choose their own provider. The answer to this argument is contained in the language of section 1396a(a)(23) itself. Plaintiffs are free to obtain medical assistance "from any institution ... or person ... qualified to perform the service or services required ... who undertakes to provide him such services." (Emphasis added.) Multnomah County no longer wishes to provide Medicaid services. Plaintiffs' free choice rights therefore no longer include Plaintiffs next rely on certain parts of the Medicaid "Residents' Bill of Rights," 42 C.F.R. § 442.311, in particular those portions protecting residents' privacy and free association interests, 442.311(g)(1) and (2) and 442.311(i)(1), and provisions preventing transfers and discharges unless for medical reasons or nonpayment, 442.311(c)(1)-(3). However, these regulations pertain only to the ongoing provision of medical services. They do not require the States to limit a provider's right to withdraw upon expiration of the provider agreement, nor do they impose obligations on the States to step in and preserve the status quo whenever a provider exercises its right to withdraw from the program.

Edgefield Manor. See Roberson v. Wood, 500 F.Supp. at 860 (quoted supra); see also O'Bannon v. Town Court Nursing Center, 447 U.S. 773, 785, 100 S.Ct. 2467, 2475, 65 L.Ed.2d 506 (1980) (holding that section 1396a(a) (23) does not confer a right on a recipient to enter or continue to receive benefits at an unqualified home).

Plaintiffs' final Title XIX argument is based on section 1396a(a)(19), which provides that a State plan for medical assistance must:

provide such safeguards as may be necessary to assure that eligibility for care and services under the plan will be determined, and such care and services will be provided in a manner consistent with simplicity of administration and the best interests of the recipients.

Plaintiffs' argument based on this provision is not without force. Plaintiffs are infirm, elderly, and variously afflicted with heart disease, stroke disorders, chronic brain syndrome and other disabilities. They allege that the closure of Edgefield Manor, and the resulting involuntary transfers and destruction of interpersonal relationships, will cause irreparable emotional and physical injuries. The damage to individuals in plaintiffs' circumstances in terms of physical and emotional deterioration and increased incidence of mortality as a result of "transfer trauma" has been recognized by this and other federal courts on numerous occasions. See, e.g., Brede v. Director for Department of Health, 616 F.2d 407, 412 (9th Cir. 1980); Yaretsky v. Blum, 629 F.2d 817, 821 (2d Cir. 1980), reversed on other grounds, --- U.S. ----, 102 S.Ct. 2777, --- L.Ed.2d ---- (1982). One expert has testified for plaintiffs that "a transfer of the patients ... (at Edgefield) will quite probably result in the deaths of a substantial number of those patients." Record, Vol. 2, at 276. Plaintiffs contend that any plan for medical assistance which allows mass transfers under the circumstances such as are presented here cannot possibly meet the requirement of section 1396a(a)(19) that care and services be provided "in a manner consistent with simplicity of administration and the best interests of the recipients."

Though we are not unsympathetic to plaintiffs' claims, we conclude that section 1396a(a)(19) is not the proper avenue for their relief. Section 1396a(a)(19) does not give plaintiffs a substantive right to remain at Edgefield Manor or to be transferred as a single group with full staff to a new facility. Section 1396a(a)(19) is not the sort of specific condition for receipt of federal funds which can be said to create substantive rights in Medicaid recipients. See Pennhurst State School and Hospital v. Halderman, 451 U.S. 1, 17, 24, 101 S.Ct. 1531, 1540, 1543, 67 L.Ed.2d 694 (1981):

(I)f Congress intends to impose a condition on the grant of federal moneys it must do so unambiguously. By insisting that Congress speak with a clear voice, we enable the States to exercise their choice knowingly, cognizant of the consequences of their participation.

Id. at 17, 101 S.Ct. at 1540 (citations omitted).

Section 1396a(a)(19) speaks to two sometimes conflicting goals: simplicity of administration and the best interests of the recipients. Whether a state plan strikes a proper balance between the two is a decision better left to the Department of Health and Human Services and the state agencies responsible for implementing Title XIX. We are not in a position to second-guess the balance chosen by the State of Even if section 1396a(a)(19) is sufficiently clear to give Medicaid recipients some substantive rights against the States, section 1396a(a)(19) does not create the rights claimed here. Section 1396a(a)(19) must be considered in light of the legislative scheme as a whole. The Medicaid program is not intended to meet all the medical needs of recipients. Rather, the goal is to provide medical assistance "as far as...