“[W]e confront the question whether the proscription of discrimination may require placement of persons with mental disabilities in community settings rather than in institutions.”

“The answer … is a qualified yes.”

“A public entity shall administer services, programs and activities in the most integrated setting appropriate to the needs of qualified individuals with disabilities.”

“A public entity shall make reasonable accommodations in policies, practices and procedures …

unless … making the modifications would fundamentally alter the service, program or activity.”

Two women, Lois Curtis and Elaine Wilson, who were institutionalized at Georgia Regional Hospital …

sued Tommy Olmstead, the Commissioner of the Georgia Department of Human Resources

Ruled for Ms. Wilson & Ms. Curtis

Found that Georgia “could provide services to [Ms. Wilson & Ms. Curtis] in the community at considerably less cost than is required to institutionalize them.”

Sent the case back to the trial judge on cost of community care

Asked “whether the additional expenditures … would be unreasonable given the demands of the State’s mental health budget.”

“First, institutional placement of persons who can handle or benefit from community settings … perpetuates unwarranted assumptions … that persons so isolated are incapable or unworthy of participating in community life.”

“Second, confinement in an institution severely diminishes the everyday life activities of individuals, including: Family relations, Social contacts, Work options, Economic independence, Educational advancement, and Cultural enrichment.”

When “the State’s treatment professionals have determined that community placement is appropriate,

the transfer from the institution to a less restrictive setting is not opposed by the affected individual,

and the placement can be reasonably accommodated, taking into account ◦ the resources available to the State ◦ and the needs of others with disabilities.”

When the State, “generally rely[ing] on the reasonable assessments of its own professionals,” determines that habilitation needs can only be met in an institution.

When “in the allocation of available resources, immediate relief … would be inequitable, given the responsibility the state has undertaken for the care and treatment of a large and diverse population of persons with disabilities.

“If the State were to demonstrate that it had

a comprehensive, effectively working plan for placing qualified individuals 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,

the reasonable-modifications standard would be met.”

“[T]he range of facilities the State maintains for the care and treatment of persons with diverse mental disabilities,

and its obligation to administer services with an even hand.”

“Nor is it the ADA’s mission to drive State’s to move institutionalized patients into an inappropriate setting, such as a homeless shelter.”

“We emphasize that nothing in the ADA or its implementing regulations condones termination of institutional settings for persons unable to handle or benefit from community settings.”

“Nor is there any federal requirement that community-based treatment be imposed on patients who do not desire it.”

Source: Centers for Medicare and Medicaid Services

Total Nursing Home Population in the United States:

~1.35 Million

SOURCE: CMS Minimum Data Set 2.0 (1st Q 2010)

Medicaid: 54% (729,000) Medicare: 25% (337,500) VA: 1% (13,500) Self/family: 13% (175,500) Private insurance: 9% (121,500)

SOURCE: CMS MDS 2.0

Total: $61 Billion Total: $45 Billion

Institutional Spending: Nursing Homes: $49 Billion ICF/MR (for persons

with developmental disabilities):

$12 Billion

Community Spending: Home and Community

services (waivers, all disabilities): $30 Billion

Personal Care option: $11 Billion

Home Health: $4 Billion

Under 30: .5% (6,750) 31 to 64: 14% (189,000) 65 to 74: 14% (189,000) 75 to 84: 28% (378,000) Over 85: 50% (675,000)

An acute care hospital: 61%

Another nursing home: 13%

A private home with no home health services: 10%

SOURCE: CMS MDS 2.0 (1st Q 2010)

United States: 23% (310,500) California: 27% (26,460) Illinois: 25% (18,250) Louisiana: 16% (4,000) Michigan: 30% (11,700) New York: 21% (22,260) Oregon: 35% (2,555) Texas: 20% (18,600) Utah: 37% (1,872)SOURCE: CMS MDS 2.0 (1st Q 2010)