Frew v. Gilbert

109 F.Supp.2d 579

Linda FREW, et al., Plaintiffs, v. Don GILBERT, et al., Defendants.

Civil Action No. 3:93CA65.

United States District Court, E.D. Texas, Paris Division.

August 14, 2000.

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Susan F. Zinn, San Antonio, TX, Jane Swanson, Law Offices of A. Rodman Johnson, The Woodlands, TX, for Plaintiffs.

John Cornyn, Attorney General of Texas, Andy Taylor, Assistant Attorney General, Linda S. Eads, Deputy Attorney General, Toni Hunter, Chief, General Litigation Div., Edwin N. Horne, Assistant Attorney General, General Litigation Div., Austin, TX, for Defendants.

MEMORANDUM OPINION

JUSTICE, Senior District Judge.

Table of Contents
PART ONE: FINDINGS OF FACT REGARDING VIOLATIONS OF CONSENT DECREE
Background and Procedural History
Issue I: Outreach
A. Overview
B. Findings of Fact: Outreach
1. Knowledge and Understanding
2. Transportation
3. Receipt of Services after Oral Outreach
4. Low Participation Rates
5. Insufficient Staffing
C. Violations of Decree: Outreach
D. Providers' Requests for Outreach: Findings of Fact Regarding
Violations of Decree
E. Outreach Reports: Findings of Fact Regarding Violations of Decree
Issue II
Medical and Dental Checkups
A. Overview
B. Findings of Fact: Checkups
1. Medical Checkups
2. Dental Checkups
a. Services
b. Provider Recruitment

3. Teens
4. Abused and Neglected Class Members
C. Violations of Decree: Checkups
1. Principles of Statutory Interpretation
a. Structure and Context
b. Legislative Intent
2. Waiver
3. The Cases
Issue IV: Managed Care
A. Defendants' Managed Care Programs
B. Findings of Fact: Receipt of Services by Class Members Enrolled
in Managed Care
1. Overview
2. Inaccurate and Inflated Data
3. THQA Focus Studies
4. Comparing Managed Care and Fee-for-service Systems
5. Incomplete Checkups
6. Problems with the Medical Home and Primary Care Provider
Models
a. The PCP
b. Crowded Clinics and Emergency Rooms
7. Access to Specialists
8. Access to Pediatric Care and Mental Health Services
9. THQA Provider and Consumer Studies
10. Self-Reporting by Class Members
a. B.M. and Samantha
b. C.H. and Sons
c. C.O
C. Violations of Decree: Receipt of Services by Class Members Enrolled
in Managed Care
D. Children of Migrant Farmworker Families
1. The Problem
2. Findings of Fact Regarding Violations of Decree
E. Training of Health Care Providers in the Managed Care System
Findings of Fact Regarding Violations of Decree
F. Data Collection in the Managed Care System: Findings of Fact
Regarding Violations of Decree
Issue V: Toll-Free Numbers
A. Overview
B. Findings of Fact: Prompt Answering of All Calls
C. Violations of Decree: Prompt Answering of All Calls
1. Abandonment Rates
2. Waits in Queue
3. Unit of Measurement
D. Knowledgeable, Helpful, and Polite: Findings of Fact Regarding
Violations of Decree
Issue VI: Case Management
A. Role and Importance of Case Management
B. Findings of Fact
1. The Need
2. Utilization
3. Sufficient Staffing
4. The Safety Net
5. Recruitment
C. Violations of Decree
Issue VII: Outcome Measures
A. Overview
B. Findings of Fact Regarding Violations of Decree
1. Joint Notice Measures
2. Unilateral Substitution of Measures
3. Corrective Action Plans

4. Timing
Issue VIII: Training for Health Care Professionals
A. Findings of Fact
B. Violations of Decree
PART TWO: DEFENDANTS' OBJECTIONS TO ENFORCEMENT OF CONSENT DECREE
Issue I: Enforcement of the Medicaid Statute
A. Law of the Case
B. Supreme Court Jurisprudence on Enforceable Rights
C. The EPSDT Provisions of the Medicaid Act
Issue II: Eleventh Amendment Objection
A. Defendants' Objection
B. Lelsz v. Kavanagh
1. Overview
2. The Holding: A Closer Look
3. The Narrowing of Lelsz
4. An Untenable Distinction
C. Application
1. Enforcement of Provisions Guaranteeing Services
a. Outreach
b. Services
c. Managed Care
2. Enforcement of Provisions Requiring Reporting of Data and
Information
a. Reporting
b. Outcome Measures and Corrective Action Plans
3. Enforcement of Training and Toll-Free Line Provisions

CONCLUSION

PART ONE: FINDINGS OF FACT REGARDING VIOLATIONS OF DECREE

Background and Procedural History

This civil action, filed on September 1, 1993, concerns the alleged failure of the State of Texas to implement a Medicaid program that assures that indigent children and youth receive timely, comprehensive health care. The case was brought by a class of more than one and one-half million indigent children in Texas who are entitled to health benefits through the Early Periodic Screening, Diagnosis and Treatment program ("EPSDT"). See 42 U.S.C. §§ 1396a(a)(43)¹; 1396d(r).² In Texas, the program is referred to as the "Texas Health Steps" program, which is administered jointly by the federal government and the Texas Health and Human Services Commission. EPSDT is intended to be "the nation's largest preventive health program for children." H.R. 3299, 101 ^st Cong. § 4213 (1989). It is "among the most important programs that the Texas Department of Health runs." Order Concerning Fairness of Consent Decree at 8 (filed January 25, 1996)(hereinafter "Fairness Order")(internal quotes omitted).

The purpose of the EPSDT program is to ensure that poor children receive comprehensive health care at an early age, so that they will develop fewer health problems as they grow older. EPSDT is designed to provide health education, preventive care, and effective follow-up care for conditions identified during check-ups. Preventive health care identifies health problems that may respond to early treatment but, if left untreated, may instead lead to serious health conditions. For example, a heart murmur detected during an EPSDT screening, if untreated, could lead to heart failure. Severe anemia, if untreated, could result in behavioral problems and reduced mental capacity. Other important components of the EPSDT program include immunizations, parental education, assistance with scheduling appointments and transportation assistance, and coordination of EPSDT and other programs serving Medicaid-eligible children.

After two years of extensive negotiation following the filing of this case, the parties proposed a partial consent decree to this court in July of 1995. During a fairness hearing held in December of that year, the parties urged the court to approve the proposed decree. The court approved the decree as fair, reasonable, and adequate on February 16, 1996. Per the agreement of both parties, the decree expressly retains the court's jurisdiction to rectify violations of its terms, and provides a mechanism to invoke this jurisdiction. Consent Decree, ¶ 303.³

The Plaintiffs' Claims

Currently pending before the court is plaintiffs' motion to enforce multiple provisions of the consent decree with which defendants allegedly have not complied. Specifically, plaintiffs allege that defendants have failed to: 1) implement properly the outreach program and deliver required outreach reports; 2) assure that all class members receive medical and dental checkups; 3) develop and implement annual corrective action plans both for counties that lag behind the statewide average for checkups and for the state's medical transportation system; 4) operate the state's managed care system consistently with the mandates of the decree; 5) operate toll-free numbers so as to ensure that all calls are answered promptly by a knowledgeable and helpful staff member; 6) provide case management to all class members who need it, statewide; 7) develop methods to study each agreed health outcome measure; and 8) provide EPSDT training for health care providers.

The Defendants' Responses

Defendants deny that plaintiffs are entitled to any relief sought, and maintain that they are in full compliance with the decree. In addition, they argue that in interpreting the consent decree to require certain specific actions by defendants, plaintiffs seek to modify the decree, and not merely to enforce it. In the alternative, defendants argue that a federal court's jurisdiction over a state official is limited by the Eleventh Amendment to requiring compliance with federal law. Therefore, defendants argue that the decree itself may not be enforced against them to the extent that it goes beyond the scope of simple compliance with federal law.

The Hearing and Memorandum Opinion

A hearing was held from March 13 — March 17, 2000, on plaintiffs' motion to enforce the decree, and evidence was heard on each of the above-listed issues. Following the hearing, the court invited the parties to submit briefs on several of the legal issues involved in this case. Additionally, plaintiffs submitted proposed orders of enforcement, to which defendants responded. The following is a memorandum opinion that grants plaintiffs' motion to enforce the decree in part. Part One of the opinion details the court's findings of fact regarding defendants' specific violations of the consent decree, as interpreted by the court. Part Two addresses defendants' objections to the enforcement of various provisions of the decree. The court's Order of Enforcement accompanies these findings of fact and conclusions of law as a separately issued order.

I. Issue One: Outreach

A. Overview

The decree elaborates in detail the defendants' obligations to conduct outreach efforts aimed at increasing participation and the receipt of needed services. For example, it requires defendants to inform all class members about checkups and other services, and to assist them in arranging for checkups and needed care. ¶¶ 10-74. These decree paragraphs stem from the federal requirement that a state plan for medical assistance that details the state's obligations pursuant to their participation in the federal Medicaid program must "provide for" the "informing" of all eligible recipients of EPSDT services of the availability of those services. 42 U.S.C. § 1396a(a)(43)(A). The decree also requires def...