PRINTER FRIENDLY
 

Introduction

Most people want to avoid nursing home care.  Many people believe that assisted living provides them with something better: choice, control, independence, and safety in a "non-institutional, community-based setting."  What is not widely known is that the protections for nursing home residents provided by the federal Nursing Home Reform Law do not apply to Assisted Living facility (ALF) residents, even those who are eligible for nursing home care and receive Medicaid for ALF services under a home and community-based waiver.  Moreover, no separate federal legislation protects ALF residents. 

Over the years, Medicaid spending for long-term care services has shifted significantly from nursing home care to home and community-based alternatives, including services in ALFs.  Between 1995 and 2007, Medicaid spending on nursing home care declined from 61% to 47% of all Medicaid spending in long-term care, while Medicaid spending on home and community-based waiver programs, including ALF care, increased from 9% to 27% of Medicaid's long-term care spending.[1]  In 2002, 41 states used Medicaid to pay for assisted living services for more than 100,000 residents.[2]

Earlier this month, ALF residents in Washington State suffered a set-back in legal protection, highlighting the need for federal legislation.  In Washington State, a federal district court rejected limited state law protections for ALF residents whose facilities terminate their Medicaid participation. In contrast, residents of nursing facilities that participate in the Medicaid program have the benefit of a 1999 amendment to the federal Nursing Home Reform law, which offers broader protections to residents in identical circumstances.

Assisted Living Residents Lack Protection When their Facilities Terminate Participation in the Medicaid Program.

In 2007, ALFs in Washington State and elsewhere began voluntarily terminating their Medicaid provider agreements with the States and evicting their Medicaid residents.  The residents' experiences were shocking.  Not atypical was the story of a 98-year old woman in Sumner, Washington who had spent more than $300,000, her life savings, paying privately for her stay at an ALF owned by Assisted Living Concepts.  She was told that the facility would not accept Medicaid for her care and that she would have to leave, despite the fact that the facility had promised repeatedly over the nine years that she had paid privately that she could stay as a Medicaid beneficiary when her private funds ran out.[3]

Although Assisted Living Concepts, the chain that owns the woman's ALF, evicted residents from its facilities across the country, only Washington State enacted protective legislation.  The protection for residents who were being displaced from their ALFs was limited.  As enacted, the Washington legislation required ALFs to keep only residents who were receiving Medicaid at the time of their facility's withdrawal and those who had paid privately for their stays for at least two years and who became eligible for Medicaid within 180 days of the facility's withdrawal from the Medicaid program.[4]  The law was challenged by the Washington Health Care Association, a trade association of nursing homes and assisted living facilities.  In a summary judgment decision issued this month, the federal district court in Washington State sustained the industry's challenge and struck down the law on the grounds that it violates the Contract Clause of the United States Constitution.[5] 

The Court described the legal question as whether the state law was a substantial impairment to a contractual relationship and, if so, "whether the impairment is reasonable and necessary to serve an important public purpose."[6]  It found, first, that the 2008 legislation impaired facilities' contractual relationship with the state by unilaterally invalidating the contract's termination clause, which allowed ALFs to terminate a Medicaid contract on 30 days' notice.  Next, despite acknowledging that assisted living residents "are vulnerable elderly and/or disabled adults" for whom "forced and sudden discharge poses a significant threat to the residents' emotional and physical well-being," the Court held that "the drastic measure of requiring boarding homes to continue to provide services" to certain Medicaid residents "in exchange for the Medicaid rate [that the Department of Health and Social Services] DSHS decided to pay" was neither "reasonable" nor "necessary."[7]  The Court suggested that alternative legislative solutions could have served the state's purpose "equally well without impairing the State's own contracts."[8]

The Washington federal court decision underscores the need for federal legislation to protect assisted living residents.  Significantly, similar, but broader, federal law does protect nursing home residents in the identical situation. 

Protection is Available for Nursing Home Residents when their Facilities Terminate their Medicaid Participation. 

A 1999 amendment to the federal Nursing Home Reform Law – "Continuing Rights in Case of Voluntary Withdrawal from Participation"[9] – was Congress' response to the decision of the Vencor Corporation (now known as Kindred) to terminate its nursing home Medicaid contracts and evict its Medicaid residents.  The federal law allows nursing facilities to withdraw from the Medicaid program, but only prospectively.  All individuals living in a nursing facility at the time of a nursing facility's withdrawal from the Medicaid program are protected, including those who become eligible for Medicaid at some undefined time in the future.  The nursing home industry did not challenge the 1999 law.  Notably, the Contract Clause, an important vehicle for challenging the Washington state law, does not apply to the federal government.

Conclusion

As assisted living becomes an increasingly prominent part of the country's long-term care system, assisted living residents need to be adequately protected.  Congress should extend Medicaid nursing home protections to assisted living residents who use Medicaid and should consider whether additional, broader federal legislation is appropriate as well.