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Full Opinion
Michela LEOCATA, Through Matthew T. GILBRIDE, Esq., Conservator over her Estate and Next of Friend, Plaintiff,
v.
Patricia WILSON-COKER, Commissioner, Connecticut Department of Social Services; and Tommy G. Thompson, Secretary of the U.S. Department of Health and Human Services, Defendants
United States District Court, D. Connecticut.
*146 Raymond J. Rigat, Clinton, CT, for Plaintiff.
Carolyn Aiko Ikari, U.S. Attorney's Office, Richard J. Lynch, Tanya Feliciano, Hartford, CT, for Defendant.
RULING ON MOTIONS TO DISMISS AND MOTION FOR PRELIMINARY INJUNCTION
DRONEY, District Judge.
Plaintiff Michela Leocata ("Leocata") brought this action against Patricia Wilson-Coker, Commissioner of the Department of Social Services of the State of Connecticut ("Commissioner") and Tommy G. Thompson, Secretary of the United States Department of Health and Human Services ("Secretary") in connection with their roles in administering the Title XIX ("Medicaid") program.[1] Leocata alleges violations of 42 U.S.C. § 1983, Title II of the Americans with Disabilities Act ("ADA"), and the Due Process and Equal Protection clauses of the Fifth and Fourteenth Amendments. She seeks declaratory and injunctive relief, attorney's fees and costs. The Secretary and the Commissioner have filed motions to dismiss the complaint for lack of standing and for failure to state a claim upon which relief can be granted. The plaintiff has filed a motion for a preliminary injunction seeking temporary relief during the pendency of this case and its appeal, if applicable. For the reasons that follow, the motions to dismiss are granted and the motion for a preliminary injunction is denied.
I. Facts[2]
Leocata is an elderly woman with advanced dementia who resides at Arden Courts in Farmington, Connecticut. Arden Courts is an assisted living facility ("ALF") that provides residential care to elderly persons with various forms of dementia who do not need the extent of *147 skilled nursing care provided at a traditional nursing home. Leocata pays for her care at Arden Courts; her assets, however, are rapidly depleting and soon will be insufficient to cover the cost of that care.
Leocata contends that the Medicaid program under Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq., and the relevant state statutes only allow benefits to be paid to skilled nursing care facilities ("NF") and disallow payments to ALFs, even though the cost of care is more expensive at skilled nursing care facilities. Once Leocata cannot afford to pay for her care at Arden Courts, she will be forced to relocate to a skilled nursing care facility despite the fact that she does not require all the extensive medical services such facilities provide. Moreover, Leocata alleges that a skilled nursing care facility will not be able to address her special needs adequately. She contends that other recipients of state and federal aid pursuant to the Medicaid program have their specialized medical care needs met.
Leocata maintains that she will be forced to move out of Arden Courts to a skilled nursing care facility because of her poverty and the unfairness of Medicaid paying for skilled nursing facilities, but not assisted living facilities. She also will suffer emotional distress as a result of being forced to relocate to another facility.
II. Motion to Dismiss Standard
When considering a Rule 12(b)(6) motion to dismiss, the Court accepts as true all factual allegations in the complaint and draws inferences from these allegations in the light most favorable to the plaintiff. See Scheuer v. Rhodes, 416 U.S. 232, 236, 94 S.Ct. 1683, 40 L.Ed.2d 90 (1974), overruled on other grounds, Davis v. Scherer, 468 U.S. 183, 104 S.Ct. 3012, 82 L.Ed.2d 139 (1984); Easton v. Sundram, 947 F.2d 1011, 1014-15 (2d Cir.1991), cert, denied, 504 U.S. 911, 112 S.Ct. 1943, 118 L.Ed.2d 548 (1992). Dismissal is warranted only if, under any set of facts that the plaintiff can prove consistent with the allegations, it is clear that no relief can be granted. See Hishon v. King & Spalding, 467 U.S. 69, 73, 104 S.Ct. 2229, 81 L.Ed.2d 59 (1984); Frasier v. General Elec. Co., 930 F.2d 1004, 1007 (2d Cir.1991). "The issue on a motion to dismiss is not whether the plaintiff will prevail, but whether the plaintiff is entitled to offer evidence to support his or her claims." United States v. Yale New Haven Hosp., 727 F.Supp. 784, 786 (D.Conn.1990) (citing Scheuer, 416 U.S. at 232, 94 S.Ct. 1683). Thus, a motion to dismiss under 12(b)(6) should not be granted "unless it appears beyond doubt that the plaintiff can prove no set of facts in support of his claim which would entitle him to relief." Sheppard v. Beerman, 18 F.3d 147, 150 (2d Cir.1994) (citations and internal quotations omitted), cert, denied, 513 U.S. 816, 115 S.Ct. 73, 130 L.Ed.2d 28 (1994). In its review of a 12(b)(6) motion to dismiss, the Court may consider "only the facts alleged in the pleadings, documents attached as exhibits or incorporated by reference in the pleadings and matters of which judicial notice may be taken." Samuels v. Air Transport Local 50k, 992 F.2d 12,15 (2d Cir.1993).
III. Standing
The defendants allege that Leocata lacks standing to bring this action, since she currently does not receive Medicaid benefits, nor has she demonstrated that she will become Medicaid-eligible at any given time. Defendants further allege that Leocata has shown no actual injury, since she continues to reside at Arden Courts, and that her injury may not be redressable, since it is unlikely that Arden Courts would qualify as a service provider under the Medicaid regulations.
*148 The Supreme Court has held that "a plaintiff must meet three requirements in order to establish Article III standing," those of injury in fact, causation and redressability. Vermont Agency of Natural Res. v. United States ex ret. Stevens, 529 U.S. 765, 771, 120 S.Ct. 1858, 146 L.Ed.2d 836 (2000). First, a plaintiff must demonstrate an "injury in fact" which is "concrete, distinct and palpable," and "actual or imminent, not conjectural or hypothetical." Whitmore v. Arkansas, 495 U.S. 149, 155, 110 S.Ct. 1717, 109 L.Ed.2d 135 (1990) (internal quotation marks and citations omitted). Second, a plaintiff must establish "a causal connection between the injury and the conduct complained ofthe injury has to be `fairly traceable to the challenged action of the defendant, and not... the result [of] some third party not before the court.'" Lujan v. Defenders of Wildlife, 504 U.S. 555, 560-61, 112 S.Ct. 2130, 119 L.Ed.2d 351 (1992) (quoting Simon v. Eastern Ky. Welfare Rights Org., 426 U.S. 26, 41-42, 96 S.Ct. 1917, 48 L.Ed.2d 450 (1976)). Third, a plaintiff must demonstrate a "`substantial likelihood' that the requested relief will remedy the alleged injury in fact." Stevens, 529 U.S. at 771, 120 S.Ct. 1858 (quoting Simon, 426 U.S. at 45, 96 S.Ct. 1917).
The Court finds that Leocata has presented facts sufficient to give her standing in the instant case. Due to the rapid depletion of her personal funds, she faces the imminent injury of being forced to leave Arden Courts.[3] It is undeniably true that Leocata would seek to stay at Arden Courts if Medicaid would reimburse her room and board costs there. It is also true that the declaratory and injunctive relief Leocata seeks, requiring Medicaid to provide such reimbursement, would redress her situation fully. Article III requires that a party's standing be determined prior to reaching the merits of his or her claims. Therefore, regardless of the likelihood of success of Leocata's complaint, the Court finds that she has sufficient standing to pursue that complaint here.
IV. Discussion
A. The Challenged Statute
The Medicaid program, established under Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq., is a "co-operative federal/state cost-sharing program designed to enable participating states to furnish medical assistance to persons whose income and resources are insufficient to meet the costs of necessary medical care and services." DeJesus v. Perales, 770 F.2d 316, 318 (2d Cir.1985).
States choosing to participate in Medicaid are required to comply with Title XIX's requirements and implementing regulations. 42 U.S.C. § 1396a(a) sets forth the requirements of state plans for medical assistance. Participating states must agree to fund medical services to the "categorically needy" in five general areas: (1) inpatient hospital services; (2) outpatient hospital services; (3) other laboratory and X-ray services; (4) skilled nursing facilities services, periodic screening and diagnosis of children, and family planning services; and (5) services of physicians. See 42 U.S.C. §§ 1396a(a)(13)(B), 1396d(a)(l)-(5). While states do not have to fund all medical services within those five categories, they must establish "reasonable standards... for determining ... the extent of medical assistance under the plan which ... e is "reasonable cause to believe that a person has psychiatric disabilities and is dangerous to himself or herself or others...." Conn. Gen.Stat. § 17a-503(a). Thus, the statute sets *149 are consistent with the objectives of [Title XIX]." 42 U.S.C. § 1396a(a)(17). Once a state plan is approved by the federal Department of Health and Human Services, "the federal government partially reimburses the state for the state's expenditures in subsidizing medical services for needy citizens covered by its plan." Lewis v. Thompson, 252 F.3d 567, 570 (2d Cir. 2001).
Because Medicaid only covers categorically needy persons, individuals do not become eligible for Medicaid assistance until they "spend down" their private assets below a income ceiling set by state statute. See Schweiker v. Gray Panthers, 453 U.S. 34, 37-40, 101 S.Ct. 2633, 69 L.Ed.2d 460 (1981). A Medicaid-eligible individual may receive any of three basic types of inpatient services that provide room and board: hospitals, NFs, or intermediate care facilities for the mentally retarded ("ICF/MRs"). 42 U.S.C. §§ 1396d(a)(l), (4), (14)-(16). The statute also sets forth certification standards or participation requirements for these facilities. 42 U.S.C. §§ 1396d(c), (d), (h), and 1396r; see also 42 C.F.R. §§ 440.10(a)(3)(iii), 440.150(a)(3), 441.151(b), and 483, Subparts B and I.
A "nursing facility" is defined as an institution which
(1) is primarily engaged in providing to residents
(A) skilled nursing care and related services for residents who require medical or nursing care,
(B) rehabilitation services for the rehabilitation of injured, disabled, or sick persons, or
(C) on a regular basis, health-related care and services to individuals who because of their mental or physical condition require care and services (above the level of room and board) which can be made available to them only through institutional facilities, and is not primarily for the care and treatment of mental diseases;
(2) has in effect a transfer agreement (meeting the requirements of section 1395x(l) of this title) with one or more hospitals having agreements in effect under section 1395cc of this title; and
(3) meets the requirements for a nursing facility described in subsections (b), (c), and (d) of this section.
42 U.S.C. § 1396r(a). Subsections (b), (c), and (d) set forth the requirements relating to provision of services, residents' rights, and administration and other matters.
While the statute specifies numerous requirements for NFs, the statute makes no explicit reference to ALFs. The Medicaid statute does not provide coverage for the residential or room-and-board charges of an ALF. It also does not establish any certification requirements for ALFs.
In addition to inpatient services, qualified "medical assistance" that can be provided under a state plan includes home health services and other personal care services offered to individuals who reside in their homes or in community settings other than a hospital or NF. See 42 U.S.C. §§ 1396d(a)(7), (24).
B. Equal Protection Claims
Leocata contends that the Medicaid program violates her equal protection rights under the Fifth and Fourteenth Amendments because it provides federal funding for NF room-and-board charges, but does not provide funding for ALF residential services such as Arden Courts. The parties agree that the Medicaid statute prohibits federal funding for the residential charges of an ALF.
The Equal Protection Clause "creates no substantive rights.... Instead, it embodies a general rule that States must treat *150 like cases alike but may treat unlike cases accordingly." Vacco v. Quill, 521 U.S. 793, 799, 117 S.Ct. 2293, 138 L.Ed.2d 834 (1997). Equal protection analysis is congruent under the Fifth and Fourteenth Amendments. See Adarand Constructors v. Pena, 515 U.S. 200, 218, 115 S.Ct. 2097, 132 L.Ed.2d 158 (1995); Buckley v. Valeo, 424 U.S. 1, 93, 96 S.Ct. 612, 46 L.Ed.2d 659 (1976); Weinberger v. Wiesenfeld, 420 U.S. 636, 638 n. 2, 95 S.Ct. 1225, 43 L.Ed.2d 514 (1975). The basic framework for evaluating an equal protection claim under the Fourteenth Amendment was set forth in San Antonio Independent School District v. Rodriguez, 411 U.S. 1, 93 S.Ct. 1278, 36 L.Ed.2d 16 (1973):
We must decide, first, whether [the challenged statute] operates to the disadvantage of some suspect class or impinges upon a fundamental right explicitly or implicitly protected by the Constitution, thereby requiring strict judicial scrutiny.... If not, the [legislative] scheme must still be examined to determine whether it rationally furthers some legitimate, articulated state purpose and therefore does not constitute an invidious discrimination....
Generally, suspect classes are defined as groups who historically have been subjected to discrimination; whose obvious, immutable, or distinguishing characteristics mark them as a discrete community; or who are politically powerless due to their minority status. See, e.g., Lyng v. Castillo, 477 U.S. 635, 638, 106 S.Ct. 2727, 91 L.Ed.2d 527 (1986); Plyler v. Doe, 457 U.S. 202, 216 n. 14, 102 S.Ct. 2382, 72 L.Ed.2d 786 (1982); Rodriguez, 411 U.S. at 28, 93 S.Ct. 1278. Inherently suspect classifications are those drawn upon factors such as race, religion, or alienage. See New Orleans v. Dukes, All U.S. 297, 303, 96 S.Ct. 2513, 49 L.Ed.2d 511 (1976). Such classifications must be reviewed under a strict scrutiny analysis, and may not be upheld unless they are narrowly tailored to achieve a compelling governmental interest. See, e.g., Gratz v. Bollinger, 539 U.S. 244, 270, 123 S.Ct. 2411, 156 L.Ed.2d 257 (2003).
In the instant case, the plaintiff contends that the elderly disabled constitute a suspect class against which the current Medicaid statute discriminates. Age, however, is not a suspect classification under the Equal Protection Clause. See Kimel v. Fla. Bd. of Regents, 528 U.S. 62, 83, 120 S.Ct. 631, 145 L.Ed.2d 522 (2000); Gregory v. Ashcroft, 501 U.S. 452, 470, 111 S.Ct. 2395, 115 L.Ed.2d 410 (1991); Mass. Bd. of Retirement v. Murgia, 427 U.S. 307, 313, 96 S.Ct. 2562, 49 L.Ed.2d 520 (1976). Nor is disability considered a suspect classification requiring strict scrutiny.[4] Classifications based on disability only violate the Equal Protection Clause if they lack a "rational relationship to a legitimate government purpose." Tennessee v. Lane, 541 U.S. 509, 124 S.Ct. 1978, 1988, 158 L.Ed.2d 820 (2004) (citing Bd. of Trustees of Univ. of Ala. v. Garrett, 531 U.S. 356, 366, 121 S.Ct. 955, 148 L.Ed.2d 866 (2001), and Cleburne v. Cleburne Living Ctr., 473 U.S. 432, 446, 105 S.Ct. 3249, 87 L.Ed.2d 313 (1985)). Nor does the Medicaid statute facially discriminate on the basis of either age or disability. Plaintiff has not established the existence of a suspect classification, and may not invoke strict scrutiny review on that basis.
*151 Leocata also argues that by denying her funding to stay at Arden Courts and forcing her into a more restrictive nursing facility, the Medicaid statute infringes upon her fundamental right to be free from unnecessary restraint. The Supreme Court has construed this fundamental right, however, as the right to be free from arbitrary penal restraint and involuntary physical detention. See, e.g., Hamdi v. Rumsfeld, U.S.,, 124 S.Ct. 2633, 2646, 159 L.Ed.2d 578 (2004) (holding that a citizen has an "interest in being free of detention by one's own government"); Kansas v. Crane, 534 U.S. 407, 413, 122 S.Ct. 867, 151 L.Ed.2d 856 (2002) (holding that the dangerousness of a previously convicted sexual predator may outweigh right to be free from restraint and warrant involuntary civil commitment); Foucha v. Louisiana, 504 U.S. 71, 80, 112 S.Ct. 1780, 118 L.Ed.2d 437 (1992) (invoking right of freedom from unnecessary restraint in holding that individuals only may be detained in mental institutions as long as they are adjudged dangers to society).
In contrast to that line of cases, here the state neither is committing Leocata to an institution nor confining her against her will. The Medicaid statute simply limits the payment of benefits to certain facilities. Furthermore, the law is clear that no fundamental right exists to receive Medicaid benefits at all, let alone to receive them for a particular facility. Leocata's only right is one of equal access to what benefits Medicaid provides, as long as she satisfies all the program's requirements. See DeShaney v. Winnebago County Dep't. of Social Services, 489 U.S. 189, 196, 109 S.Ct. 998, 103 L.Ed.2d 249 (1989) ("the Due Process Clauses generally confer no affirmative right to governmental aid, even where such aid may be necessary to secure life, liberty, or property interests of which the government itself may not deprive the individual"); Thomas v. Sullivan, 922 F.2d 132, 136 (2d Cir.1990) ("There is no fundamental right to the receipt of benefits from the government"). Leocata's argument that the statute impinges on her fundamental right to be free from restraint thus fails.
When a statute does not disadvantage a suspect class and does not affect fundamental rights, the general rule is that it "is presumed to be valid and will be sustained if the classification drawn by the statute is rationally related to a legitimate state interest." Cleburne v. Cleburne Living Ctr, 473 U.S. 432, 440, 105 S.Ct. 3249, 87 L.Ed.2d 313 (1985). States are afforded particularly wide latitude when the classification at issue is found in social or economic legislation. See Kadrmas v. Dickinson Pub. Sck, 487 U.S. 450, 462-63, 108 S.Ct. 2481, 101 L.Ed.2d 399 (1988); United States R.R. Ret. Bd. v. Fritz, 449 U.S. 166, 174, 101 S.Ct. 453, 66 L.Ed.2d 368 (1980); New Orleans v. Dukes, 427 U.S. 297, 303, 96 S.Ct. 2513, 49 L.Ed.2d 511 (1976). The Equal Protection Clause also does not require that classifications be perfectly drawn; a rationally-based classification will stand even if it lacks "mathematical nicety or because in practice it results in some inequity." Dandridge v. Williams, 397 U.S. 471, 485, 90 S.Ct. 1153, 25 L.Ed.2d 491 (1970).
It is the plaintiffs burden to establish that there is no "reasonably conceivable state of facts that could provide a rational basis for the classification." Heller v. Doe, 509 U.S. 312, 320, 113 S.Ct. 2637, 125 L.Ed.2d 257 (1993) (quoting FCC v. Beach Communications, Inc., 508 U.S. 307, 313, 113 S.Ct. 2096,124 L.Ed.2d 211 (1993)). A state has "no obligation to produce evidence to sustain the rationality of a statutory classification." Id. (emphasis added). Here, the plaintiff alleges that Medicaid's refusal to fund assisted living facilities is *152 irrational because not all disabled elderly persons require advanced nursing care, and requiring them to live in NFs will cause them to mentally and physically deteriorate faster.
Even accepting plaintiffs allegations as true, Medicaid regulations repeatedly have been upheld as rationally related to Congress' desire to allocate a limited pool of funds as effectively as possible: "The administration of public assistance based on the use of a formula is not inherently arbitrary. There are limited resources to spend on welfare." Schweiker v. Gray Panthers, 453 U.S. 34, 48, 101 S.Ct. 2633, 69 L.Ed.2d 460 (1981); see generally Schweiker v. Hogan, 457 U.S. 569, 102 S.Ct. 2597, 73 L.Ed.2d 227 (1982) (holding that basing Medicaid eligibility on income was rational, even though in some instances persons with higher incomes might be in greater need of medical benefits); Schweiker v. Wilson, 450 U.S. 221, 101 S.Ct. 1074, 67 L.Ed.2d 186 (1981) (holding that Congress made a rational distinction in limiting Supplemental Security Income benefits to health care facilities already receiving Medicaid funds); Harris v. McRae, 448 U.S. 297, 100 S.Ct. 2671, 65 L.Ed.2d 784 (1980) (holding that state's refusal to fund medically necessary abortions for which no federal reimbursement was available did not violate Equal Protection Clause); Maher v. Roe, 432 U.S. 464, 97 S.Ct. 2376, 53 L.Ed.2d 484 (1977) (holding that it was rational for state to encourage natural childbirth by providing Medicaid funds for prenatal care but not for nontherapeutic abortions); Lewis v. Thompson, 252 F.3d 567 (2d Cir.2001) (holding that denying Medicaid prenatal care benefits to illegal alien pregnant women does not violate equal protection). Nor does Medicaid require a state "to fund a benefit that it currently provides to no one." Rodriguez v. City of New York, 197 F.3d 611, 616 (2d Cir.1999). Furthermore, "courts are compelled under rational-basis review to accept a legislature's generalizations even when there is an imperfect fit between means and ends." Heller, 509 U.S. at 321,113 S.Ct. 2637.
In light of this precedent, the Court finds that the Medicaid classification at issue rationally relates to the federal and state governments' desire to direct its limited funds to patients of advanced nursing care facilities. The plaintiff thus has failed to state an equal protection violation upon which relief can be granted. The Court grants defendants' motions to dismiss as to Leocata's equal protection claims.
C. Due Process Claims
Leocata also alleges that the Medicaid statute violates the Due Process Clause, since she has a constitutionally protected property interest in reasonable medical assistance, and a liberty interest in staying at Arden Courts and remaining free from the confines of a skilled nursing facility.
In Harris v. McRae, 448 U.S. 297