Rosie D. v. Romney

• Decision Date: 26 January 2006
• Docket Number: No. CIV.A.01-30199-MAP.,CIV.A.01-30199-MAP.
• Citation: 410 F.Supp.2d 18
• Parties: ROSIE D. et al., Plaintiffs, v. Mitt ROMNEY et al., Defendants.
• Court: U.S. District Court — District of Massachusetts

410 F.Supp.2d 18

ROSIE D. et al., Plaintiffs, v. Mitt ROMNEY et al., Defendants.

No. CIV.A.01-30199-MAP.

United States District Court, D. Massachusetts.

January 26, 2006.

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James C. Burling, Wilmer Cutler Pickering Hale and Dorr LLP, Boston, MA, Cathy E. Costanzo, Center for Public Representation, Northampton, MA, Gabrielle E. Foote, New York, NY, John Sup Rhee, Wilmer Cutler Pickering Hale and Dorr LLP, Boston, MA, Frank J. Laski, Mental Health Legal Advisors Committee, Boston, MA, Samantha J. Morton, Hale & Dorr, LLP, Boston, MA, Steven J. Schwartz, Center for Public Representation, Northampton, MA, Sara Jane Shanahan, Griesinger, Tighe & Maffei, LLP, Boston, MA, for Anton B., Chelsea T., Chris T., Christine Q., Danielle H., Devin E., Forrest W., Jason S., Jerry N., Jose M., Joshua D., Kristin P., Marc St. L., Natisha M., Ralph B., Rosie D., Samuel L., Sarah B., Shaun E., Sheena M., Shentelle G., Terrence M., Tevin W., Tyriek H., Nathan F., Plaintiffs.

Daniel J. Hammond, Attorney General's Office, Boston, MA, Bart Q. Hollander, Attorney General's Office, Springfield, MA, Timothy M. Jones, Mass. Attorney General's Office, Springfield, MA, Stephanie S. Lovell, Attorney General's Office, Boston, MA, Deirdre Roney, Attorney General's Office, Boston, MA, John R. Hitt, Attorney General's Office, Boston, MA, Juliana deHaan Rice, Attorney General's Office, Boston, MA, Adam Simms, Deutsch Williams, Boston, MA, for EOHHS, Eric Kriss, Janice B., Robert Gittens, Stephen P. Crosby, Wendy E. Warring, Jane M. Swift, Governor Mitt Romney, Ronald Preston, Defendants.

MEMORANDUM OF DECISION

PONSOR, District Judge.

I. INTRODUCTION

On July 30, 1965, the citizens of this country, through the enactment of the Medicaid Act, Pub.L. 89-97, 79 Stat. 343, committed themselves to providing certain basic medical services to millions of low-income Americans. On December 19, 1989, Congress restated and deepened its commitment to eligible children by amending the Medicaid statute to promise that persons under twenty-one years of age would receive all reasonably necessary medical care regardless of ability to pay. From today's perspective, the scope of this commitment seems breathtaking: no Medicaid-eligible child in this country, whatever his or her economic circumstances, will go without treatment deemed medically necessary by his or her clinician.

The 1989 amendment made the provision of particular services a mandatory part of each state's Medicaid program. With special relevance to this case, the amended statute called for "early and periodic screening, diagnostic, and treatment services" (so-called "EPSDT" services) for all eligible children.

This lawsuit challenges whether the Commonwealth of Massachusetts, a conceded Medicaid participant, has kept the promise made by Congress to America's children. Specifically, it charges that Defendants have failed to provide medically necessary EPSDT services to persons who might be described as the neediest of the needy: children suffering from serious emotional disturbances ("SED") such as autism, bi-polar disorder, or post-traumatic stress disorder. Plaintiffs contend that as a result of Defendants' violation of the Medicaid statute, thousands of disabled low-income children continue to suffer needlessly.

On October 31, 2001, Plaintiffs filed their complaint, alleging violations of four specific provisions of the Medicaid Act: the EPSDT provisions, 42 U.S.C. §§ 1396a(a)(10)(A), -(a)(43), 1396d(r)(5), -(a)(4)(B)(2005) (Count I); the "reasonable promptness" provision, § 1396a (a)(8) (2005) (Count II); the methods of administration or "equal access" provision, § 1396a(a)(30)(A) (2005) (Count III); and the managed care provision, § 1396u-2(b)(5) (Count IV).

The suit named various state officials and agencies as defendants¹ (referred to variously as "Defendants" or "the Commonwealth"): Mitt Romney, the Governor of Massachusetts; Eric Kriss, the Secretary of the Executive Office of Administration and Finance; Ronald Preston, the Secretary of the Executive Office of Health and Human Services (EOHHS); Robert H. Weber, Guardian ad Litem; EOHHS; and the Massachusetts Division of Medical Assistance.

On December 19, 2001, Defendants filed a motion to dismiss, contending, among other things, that the Eleventh Amendment granted them immunity from suit. Two days later, on December 21, 2001, Plaintiffs moved for certification of a class.

On March 29, 2002, the court denied the motion to dismiss and certified a class of all current and future Medicaid-eligible children in Massachusetts under twenty-one years of age, who were (or might become) eligible to receive, but were not receiving, what Plaintiffs described as "intensive home-based services."

Defendants pursued an interlocutory appeal of the court's denial of their motion to dismiss. On November 7, 2002, the Court of Appeals for the First Circuit affirmed this court's ruling, holding that "Eleventh Amendment immunity does not protect state officials from federal court suits for prospective injunctive relief under the Medicaid Act." Rosie D. ex rel. John D. v. Swift, 310 F.3d 230, 238 (1st Cir.2002).

On March 25, 2005, the court allowed the parties' joint motion to dismiss Count IV, without prejudice. Non-jury trial with regard to liability on the three remaining counts took place from April 25, 2005, to June 9, 2005. On August 9, 2005, following submission of extensive proposed findings of facts and conclusions of law by the parties, the court heard closing arguments and took the matter under advisement.

For the reasons set forth below, the court finds that Plaintiffs have proved, by far more than a fair preponderance of the evidence, that Defendants have failed to comply with the EPSDT and "reasonable promptness" provisions of the Medicaid Act. Plaintiffs are therefore entitled to judgment with regard to liability on Counts I and II of their complaint; the court will consider prospective injunctive relief pursuant to the schedule set forth at the end of this memorandum. As for Count III, the claim under the equal access provisions of the Act, the court finds that Plaintiffs have not carried their burden of proof.

Plaintiffs are entitled to judgment on Counts I and II based on two types of violations of the Medicaid Act: (1) inadequate or non-existent medical assessments and coordination of needed services for children with serious emotional disturbances, and (2) inadequate or non-existent in-home behavioral support services for the same group.

With regard to assessment and coordination of services, the testimony of virtually all of Plaintiffs' — and for that matter Defendants' — witnesses established that compliance with Medicaid's EPSDT mandate for children with a serious emotional disturbance requires that Defendants provide, at a minimum, reasonably comprehensive medical assessments and ongoing clinical oversight of the services being provided. The evidence established over-whelmingly that, for this particularly needy group, assessment and coordination is essential to (a) identify promptly a child suffering from a serious emotional disturbance, (b) assess comprehensively the nature of the child's disability, (c) develop an overarching treatment plan for the child, and (d) oversee implementation of this plan (typically by multiple medical providers) as the needs of the child evolve.

The evidence showed, time and again, that the Commonwealth's efforts to comply with these minimum EPSDT assessment and service coordination requirements were woefully inadequate, with detrimental consequences for thousands of vulnerable children. At present, thousands of needy SED children lack comprehensive assessments; treatment occurs haphazardly, with no single person or entity providing oversight and ensuring consistency. Multiple providers offer overlapping and sometimes conflicting services, with little or no knowledgeable, overall coordination.

The second aspect of Defendants' Medicaid violation concerns the provision of in-home behavioral support services. Plaintiffs offered credible evidence that such services are a medical necessity for many SED children, particularly the roughly 15,000 Medicaid-eligible SED children in the Commonwealth who suffer extreme functional impairment. Except in rare instances, however, Defendants fail to provide these services adequately. The result of this failure is that thousands of Massachusetts children with serious emotional disabilities are forced to endure unnecessary confinement in residential facilities, or to remain in costly institutions far longer than their medical conditions require. The shortage or inadequacy of in-home support services often results in removal of a fragile child from his or her home. While such a removal is a heartbreaking consequence in and of itself, it is equally clear that the unnecessary isolation of a child in an expensive residential facility has well-documented, objective clinical sequelae. These are reflected in exacerbated symptoms including: failure at school, inability to relate positively to others, isolating depression, and assaultive or other anti-social behavior.

The undisputed evidence offered at trial made it clear that children with serious emotional disabilities are among the most fragile members of our society; their medical needs frequently extend across a spectrum of service providers and state agencies. Prompt, coordinated services that support a child's continuation in the home can allow even the most disabled child a reasonable chance at a happy, fulfilling life. Without such services a child may face a stunted existence, eked out in the shadows and devoid of almost everything that gives meaning to the gift of life. Defendants' failure to provide adequate assessments, service coordination, and home-based supportive services for Medicaid-eligible children with serious emotional disturbances was glaring...