Massachusetts has illegally forced thousands of mentally ill children ''to endure unnecessary confinement in residential facilities" because the state did not provide adequate care for them at home, a federal judge ruled yesterday, handing a major legal victory to advocates for low-income children who rely on the state-run Medicaid program for their healthcare.
The long-awaited decision by US District Judge Michael A. Ponsor found in favor of the families of eight low-income children who sued the state in 2001 over the unavailability of mental health services such as counseling, crisis intervention, and coordination of care. The ruling applies to about 15,000 low-income children statewide with serious mental health problems. Most are not currently institutionalized, but are not getting proper care while at home.
Ponsor ruled that the state does a ''woefully inadequate" job of monitoring low-income children to be sure their mental health needs are met, violating federal Medicaid law.
Ponsor gave the Romney administration and the plaintiffs until Feb. 23 to negotiate a plan to drastically expand home-based services, and he made it clear that the reforms need not cost more money. He called it ''one of the painful ironies" of the case, known as Rosie D. v. Romney, that the state wastes vast amounts of money on institutionalizing children who could have received better, cheaper care by getting counseling or other care while living at home.
''This is a stunning victory for children with serious emotional disturbances in Massachusetts and throughout the country," said Steven Schwartz, executive director of the Center for Public Representation, the nonprofit, advocacy-oriented law firm that filed the lawsuit. Since Ponsor is a federal judge, Schwartz said, his decision would set a precedent for other federal lawsuits seeking to force states to provide various services to Medicaid recipients.
Officials in the Romney administration said they were analyzing the 98-page decision, and they ponted out that Timothy Murphy, the health and human services secretary, was in Washington, D.C., yesterday. After consulting with him, ''we will decide if we are going to appeal," said Dick Powers, Murphy's spokesman.
In the past, the Romney administration has argued that the state is already improving the mental health system, having recently started small, community-based programs in Cambridge, Worcester, and other locations. The assistant attorney general representing the state argued unsuccessfully that Ponsor should consider improvements the state made after September 2004, when the judge stopped accepting new evidence.
The decision by Ponsor, whose court is in Springfield, follows a similar ruling last year that Massachusetts is not providing enough dental care for low-income children who rely on MassHealth, the state Medicaid program. The federal law that governs Medicaid requires states to ''provide all reasonably necessary medical care regardless of ability to pay," which has inspired lawsuits on behalf of the poor all over the country. Schwartz said the Rosie D. decision is the first time a federal judge has weighed in on the need for home-based mental health services.
Ponsor's ruling climaxes a long-running battle over so-called ''stuck kids" who remain longer than medically required in hospital psychiatric wards, group homes, or specialized foster care because of the very limited availability of home-based care for them. All of the children named in the suit suffer from ''serious emotional disturbances" such as bipolar disorder, autism, or post-traumatic stress disorder, and their care providers struggled to find long-term help for them at home. In the worst cases, they were needlessly placed in a psychiatric ward, the judge wrote.
In his ruling, Ponsor wrote that Roselin D., the 16-year-old girl for whom the case was named, suffered ''poorly coordinated services" for her multiple psychiatric problems, including bipolar disorder, resulting in a three-month stay in a hospital when she was 6. Now a defiant adolescent living at home, she is on the brink of being institutionalized again while her care providers argue about what is best for her, he added.
Ponsor made it clear that the state was not solely at fault for Rosie's plight: the girl suffered extreme physical and sexual abuse that left her in the care of a foster mother. But, he wrote, ''Roselin's treatment history presents a familiar picture of inadequate home supports and arbitrary limitations on services" outside a hospital because of a shortage of services.
The other children named in the suit had similarly complex lives and problems, such as a 12-year-old Brockton boy whose mother had to choose between limited care at home for his bipolar disorder or treating him as an emergency case and putting him in a hospital.
Romney administration officials estimate that 75 to 125 children are currently ''in private psychiatric hospitals when they should be in a less restrictive setting. But James C. Burling of the law firm WilmerHale, who also represented the children, said the real count of such children should include hundreds who are living in group homes or other institutions when they should be getting intensive mental health services at their homes.
Burling said that an analyst for the plaintiffs estimated that the state spends $70 million a year on unnecessary institutionalization of mentally disturbed children through MassHealth. ''The places where the kids are going . . . are the most expensive and least effective in the whole state," Burling said.
Ponsor agreed that the Romney administration had taken steps to improve services for low-income children by September 2004, setting up centralized programs that coordinate the different kinds of mental health and medical care the children require, while also supporting the children's guardians and helping during crises. However, he said, these efforts reached only a ''minuscule" portion of the 15,000 Medicaid-eligible children who could benefit from them.
In the end, Ponsor said, the case was not even close, praising the plaintiffs for providing ''prodigious" evidence that the state broke Medicaid law. A detailed analysis of 35 mentally ill children served by the Medicaid program showed that ''the vast majority of this group needed, but was not receiving," a wide range of at-home mental health services.
Under Ponsor's decision, the two sides must meet within two weeks to discuss a proposed remedy and let him know by Feb. 17 what, if anything, they have come up with.
Then, he ordered them back to court on Feb. 23, warning that he will order reforms himself if the two sides can't agree.