"Forced Institutionalization of People With Disabilities Is Illegal" - DOJ and Federal Court Ruling

Steve Gold's Information Bulletin #317 (6/2010)    

By Gail Zoppo - Jun 25, 2010 reprinted from DiversityInc.

The U.S. District Court in Jacksonville, Fla., ruled this week that Michele Haddad must be provided with services that will allow her to stay in her home. Haddad, who has a spinal-cord injury caused by a motorcycle accident with a drunk driver three years ago, was at risk of being forced into a nursing home because of changes in her caregiver situation. Although the 49-year-old woman has been on the waiting list for Medicaid community-based waiver services for two years and had alerted the state of her need, she was told that the requested services would only be available if she was admitted to a nursing home for 60 days.

In Haddad v. Arnold, the plaintiff argued that she would suffer irreparable harm if forced to enter a nursing home.

The court agreed, ordering the state to offer Haddad community-based services. The reason: Segregating people with disabilities is a form of discrimination, as found in Olmstead v. L.C. This landmark disability-rights decision determined that isolating people with disabilities in institutional settings deprives them of the opportunity to participate in their communities, interact with individuals who don't have disabilities and make daily choices. The ruling also acknowledged that unnecessary institutionalization stigmatizes people with disabilities.

The Olmstead decision, which marks its 11th anniversary this week, is not the first such case that the U.S Department of Justice has filed briefs. The DOJ is involved in several other cases in Illinois and New Jersey, as part of its mission to end discrimination against people with disabilities.

"In the Olmstead case, the court recognized that the unnecessary segregation of individuals with disabilities stigmatizes those individuals as unworthy of participation in community life," stated Assistant Attorney General for the Civil Rights Division Thomas E. Perez. "By supporting Ms. Haddad in this case, we seek to ensure that individuals with disabilities can receive services in the most integrated setting appropriate, where they can participate in their communities, interact with individuals who do not have disabilities and make their own day-to-day choices."

The Department of Justice's involvement in these cases reinforce the Obama administration's national efforts to protect the rights of all people.

"This work is a priority for the Civil Rights Division, and we are committed to aggressive enforcement of Olmstead so that we can build upon progress made over the last 11 years," said Perez earlier this week. "But our work is only one piece of a larger, administration-wide effort to make the promise of Olmstead a reality for individuals with disabilities nationwide. Real reform requires a holistic approach. As a lifelong public servant, I recognize that the most vexing problems a government faces are those that require unprecedented interagency collaboration and coordination. The unnecessary and illegal institutionalization of individuals with disabilities who would be better served, and better able to contribute to their communities, if they were provided services in integrated settings, is one of those problems."
   
Disability Advocates:

    Are there Michele Haddad's in your States?

Steve Gold, The Disability Odyssey continues

Back issues of other Information Bulletins are available online at
http://www.stevegoldada.com with a searchable Archive at this site divided into different subjects. 

To contact Steve Gold directly, write to stevegoldada@cs.com or call
215-627-7100.

--
Steve Gold, The Disability Odyssey continues

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DOJ, Olmstead, ADA and Your State. Information Bulletin #313 (6/2010)

The United States Department of Justice recently filed a brief in the case Haddad v. Arnold in the U.S. District Court for the Middle District of Florida. Because many of the arguments Florida raised as its ADA defense are similar to what occurs in your State, we want to share some of the DOJ positions.

Ms. Haddad is a woman with quadriplegia who had applied for Medicaid waiver services several years ago, who was placed on a "wait list," who was at risk of being institutionalized, and who does not want to go into a nursing home. Here is what DOJ wrote:

*  "The ADA stands entirely apart from the Medicaid Act and establishes <  its own independent requirement that, when a state provides any services to individuals with disabilities, it must do so in the most integrated setting appropriate to the individuals' needs unless doing so would fundamentally alter the nature of the service."    A state can establish a fundamental alteration defense by demonstrating it has, quoting Olmstead, a "comprehensive, effectively working plan for placing persons with ...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."

*  With regards to a "comprehensive, effectively working" plan, DOJ   explained: "Defendants point to no evidence of the plan's ...   implementation date ... or stated any measurable goals for the   deinstitutionaliztion of persons with disabilities.  Instead, in a   piecemeal and post hoc fashion, the Defendants offer a parade of   affiants outlining the [existing] Florida Medicaid program's various   Medicaid Waivers. This evidence falls far short of what is required to   demonstrate that a state has a comprehensive, effectively working plan."

*  With regards to a waiting list that moved at a reasonable pace, DOJ   noted three elements:

    1.  TBI/SCI Waiver "has remained capped at 375 persons and will  remain at this cap until at least 2012," the final year of the  waiver application.

    2.  "any assessment of the relative merits of a state's effort to deinstitutionalize individuals with disabilities must be viewed not in dollar' terms, but in actual evidence that the plan is  effectively ... preventing [individuals with disabilities] from becoming a risk of institutionalization."

    3.  Such "actual evidence" requires "measurable evidence of  expansion' in view of the number of individuals on the TBI/SCI waiting list, or the length of time that these individuals remain on the waiting list."

*  With regards to an individual jumping the line or displacing people,   DOJ pointed out that Ms. Haddad was not "circumventing" any procedures,  but she "had in fact followed these procedures, but her efforts were to  no avail. Ms. Haddad remains on the waiting ist despite her first joining it in 2007."

*  DOJ concludes that "Ms. Haddad's request -- that the state provide her   with less-costly community-based services, without requiring her to   first enter a nursing home... -- is eminently reasonable."

DISABILITY ADVOCATES:

Each of these principles apply to your State - no "measurable goals," capped number of person in waivers that are not expanded even though there are waiting lists, "actual evidence" that the "plan" both  deinstitutionalizes and prevents unnecessary institutionalization, and "measurable ... expansion" in comparison to the numbers on a waiting list.

This DOJ brief fully comports with its arguments in its amicus brief in Disability Advocates, Inc. v. Paterson, 633 F. Supp.2d 184 (E.D.N.Y. 2009).

The ball is now in your backyard!  It's been 11 years since the Supreme Court issued the Olmstead decision.

Steve Gold, The Disability Odyssey continues

CMS, Olmstead, and Dear Medicaid Director

by Steve Gold

On May 20, 2010, Cindy Mann, the new CMS Director issued a "Dear Medicaid Director."  She reminded each State Medicaid Director that "in the Olmstead decision [in 1999], the Supreme Court held that unjustified institutional isolation of people with disabilities is a form of unlawful discrimination under the ADA."  "The demand for community services continues to grow, and many individuals in need of these services struggle without them.  In addition, State budget constraints threaten the progress that has been achieved, raising concerns about compliance with the ADA and Olmstead."

The Dear Medicaid Director letter provides your State with information "on new tools for community integration, as well as to remind States of existing tools that remain strong resources" to end the unlawful discrimination. [The letter can be downloaded. Google CMS and Dear Medicaid Director letter.]

Here is a partial list of those tools.  Does your State use them all?

*  CMS offers technical assistance to States to support greater   ommunity-based system capacity to "advance opportunities for the full   community inclusion of all individuals" and for quality in home and   community based services [HCBS].  Has your State asked CMS for any   technical assistance?

* MS provides technical assistance to States for properly implementing   PASRR [Preadmission Screening and Resident Review] so that people with   mental illness and intellectual disabilities are not dumped into nursing   facilities.

*  Identifies a technical assistance guide entitled Long Term Services   and Supports in a Managed Care Delivery System' so States could make   sure community-based services were integral to those services.

*  Identifies three opportunities for States to advance access to   affordable housing as a means to maximize community living.  Has your   State applied for any of these?

*  Notes that Section 1915(i) permits your State to provide HCBS as a   State plan option to service persons with disabilities in the community   without linking the benefit to either a current or future need for   institutional care.  CMS pointed out that the 2010 Affordable Care Act   [i.e., health reform legislation] expanded this section and "offers   great promise as a tool to prevent instituitonalization."  Has your   State applied for this?

*  Notes that Section 1915(j) permits your State to provide   "self-directed personal assistance or other HCBS for individuals who   would otherwise receive State plan personal care or HCBS waiver   services." Has your State applied for this?

*  Reminds States that Medicaid's state plan Personal Care optional   benefit "can play an important role in supporting people in their homes   and communities, provide necessary help to care givers and can prevent   or delay the need for institutional care."

*  Reminds your State that the "self-direction service delivery model is   available under many MA authorities.... Self-direction affords   individuals an important option for maximum choice and control over   their services, and can be an important tool for the expansion of   integration community services."  Does your State provide for   self-direction?

*  Identifies federal grants and enhanced Medicaid funding to support   more balanced State long-term care services and to improve access to   HCBS.  Has your State applied for any of these?

*  Notes that there were more than 200 Aging and Disability Resource   Centers through out the country which are supposed to streamline access   to long-term services and supports.

*  Reminds your State that after 10/1/2010, each nursing facility though   out the country must ask residents if they are "interested in learning   about the possibility of returning to the community," and nursing   facilities will be required to make referrals of individuals to ADRCs,   CILs, AAAs.

*  Notes that a person-centered hospital discharge planning grants have   been awarded, and they are supposed to assist States in "developing   hospital discharge planning structures and processes that will place   greater emphasis in after-care plans, including community-base   alternatives to institutional care."

WHAT ADVOCATES SHOULD DO:

Send the "Dear Medicaid" letter to your Governor, Lt. Gov, Speaker of the House, Senate and House Health and Human Services Chairpersons, head of all State agencies dealing with aging and disability programs;

Get with other disability and aging organizations in your state and go over all the points in the Dear Medicaid Director letter to see what your state has and has not availed themselves of;

Develop a strategy on how to get your state to move forward on the offers made in the Dear Medicaid Director letter;

    Steve Gold, The Disability Odyssey continues

2010 Patient Protection and Affordable Care Act and Olmstead Implementation for Disabled and Elderly. Information Bulletin #311 (5/10)

by Steve Gold

With the recent enactment of the 2010 Patient Protection and Affordable Care Act in March, there are a number of critical long-term services supports (LTSS) provisions that your States can implement that will dramatically improve community services opportunities. States may not act if not pushed by advocates!!! These new statutory provisions make the ADA and the Olmstead decision more powerful than at anytime since 1999.

Some background information: the Supreme Court in Olmstead rejected the States' argument that Medicaid "reflected a Congressional policy preference for treatment in the institution over treatment in the community." The Court also emphasized that "since 1981, Medicaid has provided funding for state-run home and community-based care through a waiver program."

It was this existence and availability of Medicaid Waivers which moved the Court in Olmstead to hold that unnecessary institutionalization was discrimination under the ADA. Since then, Congress has offered States additional Medicaid opportunities to end discrimination. For example, States were offered Real System Choice Grants and Money Follows the Person Grants to reform their systems and get people out of institutions.

With the 2010 new health care reform statute, States will have many more Medicaid community-based program opportunities to end discrimination - IF they take advantage of these new LTSS opportunities and apply.

Four provisions of the 2010 Act will allow states to offer more home and community services. States will have no longer have excuses to continue their discriminatory funding practices. Advocates should work with your State to implement these LTSS opportunities. These programs become effective October 2011 or before, so advocates should begin now to make sure your State and your Medicaid officials take advantage of these provisions. Here they are:

1. Community First Choice Option (Section 2401)
For persons with disabilities regardless of age, who meet your State's institutional level of need criteria (nursing home, ICF-MR, IMD) the Federal Medical Assistance Percentages (FMAP) - the federal reimbursement to your state for community-based attendant services and supports in the community - will be increased by six percent.

Since community-based attendant services and supports are the critical need to live in the community, your State will be able to focus on this service.

When this option is selected, these services will be mandatory and not a "waiver." Cost caps, cost neutrality and waiting list restrictions are not part of this program. Therefore, States can provide community-based services and supports to persons with the most severe disabilities and receive enhanced federal funds. Transition costs from nursing homes and other institutions are also permissible and will receive the increased FMAP. These transition costs can now include first month's rent and utilities, deposits, and household supplies.

2. Removal of Barriers to Providing Home and Community Based Services. (Section 2402).
This provisions broadens the scope of permissible Medicaid home and community-based services under the current optional State Plan1915 (i) program. For persons with disabilities regardless of age, who meet your State's institutional level of need criteria and for whom services do not exceed the institutional costs, States can now include services which could not in the past be approved under section 1915 (i).

States cannot cap the number of people who receive these services but can target the benefits to people with specific conditions as well as based on functional need. Services must be provided statewide. They also raised financial eligibility from 150% of poverty to 300% of SSI.

Simply stated, the improved optional 1915 (i) when selected by your state will act as mandatory community services.

3. Money Follows the Person Rebalancing Demonstration. (Section 2403).
This provision extends the federal support for MFP from 2011 to 2016 by adding more than $2 billion to provide enhanced FMAP so that States which did not sign up for MFP in the past can now have the opportunity. One use of these funds is to reimburse states persons with disabilities regardless of age, whom your State moves from the institution to the community and their own homes and apartments. Also, Congress reduced the eligibility requirement that a person be in nursing home from 6 months to 90 days.

4. "Incentives for States to Offer Home and Community-Based Services as a Long-Term Care Alternative to Nursing Homes," a Rebalancing Incentive Payment Program. (Section 10202).
This provision provides for enhanced FMAP from 2011 through 2015 for States that "rebalance" their long-term expenditures so that more Medicaid funds are expended on community-based services rather than to nursing homes and ICF-MR facilities.

For those most unbalanced States (i.e., States that spent less than 25% of Medicaid LTC funds in the community), their Federal Medical Assistance Percentages - the federal reimbursement - will be increased by five percent for increased services in the community until they reach at least 25% spending on community services.

States that spent between 25% and 50% of their Medicaid LTC in the community will receive an enhanced two percent increase in federal match until they reach at least 50% spending on community services.

States receiving this funding have till 2015 to reach these goals.

To receive this funding, states must make "structural changes" in their Medicaid program. States must develop a "single entry point" so that before a person goes into a nursing home they will be offered real community-based services; States must use a standardized assessment instrument to assess what services a person needs to stay in the community; and States must provide real case management services for eligible persons.

Congress appropriated $3 billion for these rebalancing. States must apply and submit a plan to HHS/CMS. All funds must be used for new or expanded home and community-based services.

DISABILITY AND ELDERLY ADVOCATES:

The 2010 health reform act presents many opportunities, however as you all are very aware, your States and Medicaid officials will implement these changes only if they are pushed by you.

Get to your Medicaid officials now. Make sure they know about and are planning to take advantage of these new provisions. If they do not take advantage, they will have no defenses against Olmstead lawsuits in the future. Congress has given them the tools to provide home and community services and to stop discriminating. We must work with the States to make them implement these opportunities. If they don't - using Olmstead as a powerful advocacy/legal strategy is a resource we have.

DON'T MOURN ORGANIZE!

Steve Gold, The Disability Odyssey continues

Back issues of other Information Bulletins are available online at http://www.stevegoldada.com with a searchable Archive at this site divided into different subjects.

To contact Steve Gold directly, write to stevegoldada@cs.com or call 215-627-7100.

DEFENDING OUR FREEDOM: ADAPT's Call to Action for Home and Community in America. (2/2010)

Image via Wikipedia

by Steve Gold

We The People hold our government accountable for enforcing our rights.

As the 20th Anniversary of the signing of the Americans with Disabilities Act draws near, the disability community is not busy celebrating because we are literally in a fight for our lives and our most basic freedoms.

Eleven years ago, in the Olmstead decision, the Supreme Court said that Americans with disabilities have the right to live in the most integrated setting. Yet today, states are responding to budget shortfalls by drastically cutting home and community-based services. These draconian cuts are forcing seniors and people with disabilities into nursing facilities and other institutional settings because they don't have the services they need in the community to remain independent.

As states cut vital services, the federal government, which is charged with protecting our civil rights and enforcing the law, is simply standing by - silent - while Americans with disabilities have their most basic freedoms taken away by the states.

The disability community cannot sit by as our freedom is negotiated away in back room budget deals. We must take action!

DEFENDING OUR FREEDOM is a three-prong national campaign initiated by ADAPT to organize the disability community to:

* Demand that the Obama administration fulfill its duty to aggressively protect the civil rights of disabled Americans and enforce the Americans with Disabilities Act/Olmstead decision;

* File complaints with the Health and Human Services Office for Civil Rights and the U.S. Department of Justice that document the violation of rights of individuals who have been forced into institutional settings, denied community services, or have had their community services reduced as well as complaints that document the state policies and budget cuts that violate our rights; and

* Document the disability community's efforts to fight back against state cuts so that we can learn from each other's efforts, rally others to join our fight, and hold public officials accountable when they do not support our freedom.

I. DEFENDING OUR FREEDOM: Demanding action by the Obama administration

The federal government is responsible for enforcing federal law and assuring that states comply with the Americans with Disabilities Act/Olmstead decision. ADAPT is demanding that the federal government affirmatively and aggressively enforce the Olmstead decision. To do this, the Health and Human Services Office for Civil Rights and the U.S. Department of Justice, must:

1. Accept, investigate and resolve individual and systemic complaints which document state policies and budget cuts that threaten the freedom of Americans with disabilities;

2. Develop specific benchmarks/criteria for assessing state compliance, and holding them accountable. with the Olmstead decision, assess the states and publicly release this assessment on an annual basis;

3. Conduct regular, on-going compliance reviews of states for compliance with the Olmstead decision;

4. Develop "most integrated setting" criteria for determining when DOJ will step in and affirmatively enforce the Olmstead decision whether or not there has been a complaint filed;

5. With CMS, review state submissions for modifying their Medicaid State Plan and HCBS waiver services for the impact that these changes will have on the state's ability to comply with the Olmstead decision so that those changes which limit the freedom of Americans with disabilities are not approved by CMS;

6. With CMS, modify Section Q of the Minimum Data Set so that people who indicate they want to return to community living are actively assisted to do so;

7. Publicly report on the progress that has been made so that these results can be discussed in a potential meeting between Georgina Verdugo, the HHS/OCR Director, and ADAPT representatives.

ACTION TO TAKE: ADAPT is urging organizations across the country to sign on in support of these demands. If your organization would like to support this campaign, email DOF.signon@gmail.com

II. DEFENDING OUR FREEDOM: Filing complaints to protect our freedom

The Health and Human Services Office for Civil Rights and Department of Justice are charged with protecting the civil rights of Americans with disabilities who want to live in the most integrated setting. Although they are able to affirmatively enforce the law without specific complaints, these agencies typically take action only when complaints are filed. We need to file complaints that document the violation of rights of individuals who have been forced into institutional settings, denied community services, or have had their community services reduced. We must also file complaints that document the state policies and budget cuts that steal the freedom to we are entitled under the Olmstead decision.

ACTION TO TAKE: ADAPT has prepared a form you can download and fax to us toll free at 1-888-324-0787. We will forward your complaint to the Health and Human Services Office of Civil Rights, the appropriate HHS/OCR Regional office, and the Department of Justice. If you choose to file your complaint yourself, please notify us at DOF.complaint@gmail.com that you have filed a complaint and, if possible, send ADAPT a copy.

III. DEFENDING OUR FREEDOM: Fighting back and sharing our stories

Even though there are different battles in individual states, we are fighting the same fight. To strengthen these efforts across the country, our campaign will collect personal and state stories about the effects of budget cuts and the efforts to fight back against them. ADAPT has created a website (www.defendingourfreedom2010.blogspot.com where we can post information and pictures of your advocacy. This will create a public record of the disability community's efforts to stop cuts and hopefully inspire others across the country to speak up and speak out, too. State advocates can also submit individual calls to action so that we can support each other's efforts.

ACTION TO TAKE: Send submissions to defendingourfreedom@gmail.com . And remember to keep up on what groups are doing by reading the blog: www.defendingourfreedom2010.blogspot.com

Steve Gold, The Disability Odyssey continues

Back issues of other Information Bulletins are available online at http://www.stevegoldada.com with a searchable Archive at this site divided into different subjects.

To contact Steve Gold directly, write to stevegoldada@cs.com or call 215-627-7100.

Texas, One Successful Example of Ending Discrimination by Helping People Move Out of Nursing Homes

Steve Gold's Information Bulletin # 255 (7/08).

Texas has compiled impressive data regarding its commitment to move people out of nursing facilities, and its Medicaid expenditures reflect its efforts.

Between 9/1/2001 and 5/31/2008, Texas implemented its own "Money Follows the Person," and did not wait for or need the federal program. During these years, Texas moved 15,626 people out of its nursing homes.

Here are some interesting demographics:

1. 43% or 6,719 people were 64 years old or younger;
2. 53% or 8,282 people were 65 or older.
3. Of the total, 27% or 4,219 people were 85 years old or older.
4. 67 % or 10,469 people moved from the nursing facility to either live alone or live with family members or other people.
5. A breakdown of the 67 % shows that 22% or 3,438 people left the nursing facility to live alone, and 45 % or 7,032 people moved in with their families, relatives, or others .
6. 28% or 4,375 people live in assisted living and
7. 5% or 781 people live in a group homes (adult foster).

Now let's look at how Texas allocated its Medicaid expenditures:

In FY 2001, Texas spent 70.6% of its long-term care Medicaid funds on nursing homes. In FY 2006, it reduced its nursing home expenditures to 54.6%.

Conversely, in FY 2001, it spent only 29.4% of its long-term MA funds on waivers and other community-based services.

In FY 2006, it spent 45.6% in the community.

Big surprise. There is a relationship between how a state spends its money and whether or not people moved out of nursing facilities.

To determine if your state is truly committed to ending unnecessary institutionalization of people with disabilities in nursing facilities, and therefore ending discrimination against people with disabilities, look at how your state allocates its Medicaid "long-term care" expenditures. Look at the numbers of persons who moved out of nursing facilities and returned to the community. After the 1999 Supreme Court decision in Olmstead, many disability and elderly advocates waited to see how their states would implement the "integration mandate." Well, it's been nine years!

Disability and older American advocates:

Do you know how many people in your state have been moved out of nursing facilities and where they moved to? Do you state officials know this information? Can you or they find out? Since Texas can track this information, other states probably can and do, too.

In Information Bulletin # 251, we calculated by state the changes in long-term care expenditures from 1999 thru 2006, and we expect to have the FY 2007 data available soon.

Steve Gold, The Disability Odyssey continues

Happy Ninth Anniversary - Olmstead. Information Bulletin #261 (6/08).

from Information Bulletin produced by Steve Gold June 22, 1999 - The U.S. Supreme Court issued the Olmstead decision,holding that "unjustified institutional isolation of persons withdisabilities is a form of discrimination." The Court rejected the State'sargument that Medicaid statute reflected a congressional preference for"treatment in the institution over treatment in the community," pointingout that was not correct since 1981 when Medicaid provided for home andcommunity-based services and the U.S. Department of Health and HumanServices has had a "policy of encouraging" States to serve people withdisabilities in the community. The decision recognized that the ending of this discrimination would notoccur immediately. In 1999, the Court permitted States to have "waitinglists" for community services as long as such lists "moved at areasonable pace not controlled by the State's endeavors to keep itsinstitutions fully populated. "For people with disabilities, this decision was a clarion call. Nolonger, the disability and elderly advocates believed, would people beinstitutionalized if they wanted to reside in the community. Obviously,where one resides should be one's own choice. We all know, however, that the availability and allocation of fundsfrequently determines the "choice." Specifically, if you are on Supplemental Security Income, and/or your only source of income is eitheronly Social Security Disability Income or Social Security Retirement, your"choice" may be limited to where your State spends its Medicaid funds - innursing homes or in the community. AARP surveys point out that more than 90% of older Americans do not wantto reside in nursing homes, and according to the Minimum Data Set reports,the national percentages of people in nursing homes who want to live inthe community continues to increase steadily year by year (2003 -18.7%,2004 -19.9%, 2005 - 20.5%, 2006- 21.4%, 2007 - 22.0%, and 200822.8%)(check out your state http://www.cms.hhs.gov/MDSPubQIandResRep/click on MDS Activity Report and then Q1a). One might think that amount Medicaid expenditures going to nursing homeswould reflect the implementation of the Olmstead decision, nationalsurveys, and MDS data. How has your State done? Using FY 1999/Olmstead as a benchmark, we have calculated, by state, what was the percentage of Medicaid's "Long-Term Care" expenditures that wereallocated to services in the nursing institution versus in the community. The Centers for Medicare and Medicaid define "Long Term Care" to includethe total of expenditures, on the one hand, to institutions, i.e., nursinghomes, and, on the other hand, to the community, i.e., home health,personal care option and Medicaid waivers (we've limited the waiverexpenditures to aged, aged/disabled, and physical disabilities - which arethe counterparts for nursing facilities). We've followed the CMS dichotomy. Obviously, the greater the percentage of these Medicaid funds expended inthe nursing home institution, the lower the percentage in the community. It's like a scale- as one side goes down, the other increases. While thefollowing data is provided in percentages, it is critical to rememberthere are billions of dollars involved and the ratio of expendituressignificantly impacts whether one has a meaningful choice. That is, themore your State spends on nursing facilities, the less it will have tospend on the community. We receive numerous inquiries from people who do not want to beinstitutionalized in nursing homes or who are in them and want to live inthe community. The only way to achieve real "choice" is to provide peoplewith Medicaid services where they want them. "Waiting lists" for servicesare not services. Living in fear of being institutionalized or livingwith fear because one is institutionalized is not the type of a "choice"either the ADA or the Olmstead decision intended. Whether the promise of Olmstead will be achieved depends entirely on theelderly and disability advocates! Those states that have moved thepercentages to greater equality between the community and the institutionmust have terrific, effective advocates and/or empathetic electedofficials and/or compassionate administrators. For some States it is "Olmstead, happy ninth anniversary!" For manyothers, it is not. Below we provide two lists of States. The first is the FY 1999 benchmark.In FY1999, nationally, 80.8 % of Medicaid's Long Term Care funds werespent on nursing homes and19.2 % in the community. The second list provides percentages for FY 2006, the last year for whichwe have data. In FY 2006, nationally, 71.4% of Medicaid's Long Term Carefunds were spent on nursing homes and 28.6 % in the community - a shift of9.4%. (The FY 2007 data will be available later in the summer and we willupdate this information. Data is from Medstat to whom we are extremelyappreciative.)Check out how much progress your State has made since the Olmstead decision. Compare the FY1999 benchmark with FY 2006. For example,Alabama in FY 1999 spent 87.6 % of its Medicaid Long Term Care funds innursing homes and 12.4% in the community. Seven years later, in FY 2006,it spent 88.8% of its Medicaid LTC funds in nursing homes and 11.2% in the community. Using the data for your State, disability and elderly advocates should ask whether the change between FY 1999 and FY 2006 is satisfactory, whether it reflects what the Supreme Court in the Olmstead decision intended, whether it provides elderly and disabled people in your State with a choice where they want to receive services, and what the advocates will do about the pace of change. FY 1999: % of Medicaid Long Term Care Expenditures in Nursing Homes vs. % in the Community National .....80.8% LTC expenditures in nursing homes.. 19.2% in the community. Alabama ............87.6.% nursing homes............12.4 %community Alaska .............74.2 % nursing homes............35.8% community Arizona* .......... 25.5% nursing homes............74.5% community Arkansas........... 66.0% ............ 34.0% California......... 80.7% ............19.3% Colorado............70.3% ............39.7% Connecticut.........83.5 % ............16.5% Delaware............90.9% ............ 9.1% D. C................85.0% ............15.0% Florida.............87.5 % ............12.5% Georgia.............83.4% ............16.6% Hawaii..............90.3% ............9.7% Idah................71.8% ............ 28.2% Illinois............92.0% ............8.0% Indiana.............91.8% ............ 8.2% Iowa................84.5% ............15.5% Kansas..............68.8% ............ 31.2% Kentucky............78.6% .............21.4% Louisiana.......... 91.0% ............ 9.0% Maine.............. 80.0% .............20.0% Maryland............86.4% ............ 13.6% Massachus...........84.3% ............ 15.7% Michigan............85.9% .............14.1% Minnesota...........79.9% .............20.1% Mississippi.........94.0% ............ 6.0% Missouri............81.2% ............ 18.8% Montana.............75.1% ............24.9% Nebraska............85.2% ............14.8% Nevada..............80.1% ............19.9% New Hampshire.......90.6% ............9.4% New Jersey..........79.3% ............20.7% New Mexico..........87.8% ............12.2% New York ...........70.1% ............29.9% North Carolina......67.2% ...........32.8% North Dakota........95.0% ............5.0% Ohio................88.1% ............11.9% Oklahoma............85.7 % ............14.3% Oregon............. 54.9% ............45.1% Pennsylvania........96.5% ............3.5% Rhode Island........92.3% ............7.7% South Carolina......79.0% ...........11.0% South Dakota........94.1 % ...........5.9% Tennessee...........98.7 % ...........1.3% Texas.............. 73.9 % ........... 26.1% Utah................92.3 % ............7.7% Vermont............ 81.9 % ............18.1% Virginia............81.5% ...........19.5% Washington .........62.1 % ............37.9% West Virginia.......76.6 % .............23.4% Wisconsin...........78.5 % ............ 11.5% Wyoming ............83.0% ..............17% *Arizona has had a statewide managed care Medicaid program, so the figures may not accurately reflect the distribution. FY 2006: % of Medicaid Long Term Care Expenditures in Nursing Homes vs. % in the Community National...71.4% LTC expenditures in nursing homes..... 28.6% in the Community. Alabama .............88.8% nursing homes............11.2% community Alaska ............. 48.4% nursing homes............51.6% community Arizona ............ 60.6%nursing homes.............39.4% community Arkansas.............74.0% ............26.0% California.......... 51.7% ............ 48.3% Colorado............ 66.6% ............33.4% Connecticut..........80.1% ............19.9% Delaware.............86.9% ............13.1% D. C.................72.9% ............ 27.1% Florida..............87.3% ............12.7% Georgia..............83.8% ............16.2% Hawaii...............82.9% ............17.1% Idaho................59.7% ............ 40.3% Illinois.............79.5% ............20.5% Indiana..............91.9% ............ 8.1% Iowa.................75.3% ............24.7% Kansas.............. 64.1% ............35.9% Kentucky............ 80.7% .............19.3% Louisiana........... 82.6% ............ 17.4% Maine................75.0% .............25.0% Maryland.............83.5% ............ 16.5% Massachus............75.5% ............24.5% Michigan.............84.0% ............16.0% Minnesota............57.0% ............ 43.0% Mississippi..........97.6% ............ 2.4% Missouri.............70.2% ............ 29.8% Montana..............71.2% ............ 28.8% Nebraska.............79.7% ............ 20.3% Nevada...............67.8% ............32.2% New Hampshire........86.6% ............13.4% New Jersey...........79.5% ............20.5% New Mexico...........46.3% ............53.7% New York ............63.9% ............36.1% North Carolina.......56.9% ............43.1% North Dakota........ 94.3% ............5.7% Ohio.................78.9% ............21.1% Oklahoma.............73.3% ............26.7% Oregon.............. 45.1% ............54.9% Pennsylvania.........88.0% ............12.0% Rhode Island.........88.4% ............11.6% South Carolina.......79.9% ...........20.1% South Dakota.........89.5% ...........10.5% Tennessee............98.9% ...........1.1% Texas................54.4% ...........45.6% Utah.................90.2% ............9.8% Vermont..............72.8% ............27.2% Virginia.............76.9% ...........23.1% Washington ..........45.4% ............54.6% West Virginia........77.8% .............22.2% Wisconsin ...........69.7% ........... 30.3% Wyoming .............80.1% ............19.9% Steve Gold, The Disability Odyssey continues Back issues of other Information Bulletins are available online at http://www.stevegoldada.com with a searchable Archive at this site divided into different subjects. To contact Steve Gold directly, write to stevegoldada@cs.com or call 215-627-7100. --Steve Gold, The Disability Odyssey continues. Back issues of other Information Bulletins are available online athttp://www.stevegoldada.com