Plaintiffs, Washington State Medicaid beneficiaries with severe mental and physical disabilities, appeal the district court's denial of their motion for a preliminary injunction. Plaintiffs seek to enjoin the operation of a regulation promulgated by Washington's Department of Social and Health Services ("DSHS") that reduces the amount of in-home "personal care services" available under the state's Medicaid plan. The United States Department of Justice has filed a "statement of interest" [*2] in the district court supporting Plaintiffs' request for an injunction.
"Personal care services" provide assistance in performing basic life activities -- such as eating, bathing, dressing, moving from place to place, and using the toilet -- that Plaintiffs, because of their disabilities, cannot perform by themselves. To comply with Governor Christine Gregoire's executive order that directed an across-the-board reduction in all state agency expenditures, DSHS promulgated a regulation that cut the base hours of covered in-home personal care services by an average of 10 percent per beneficiary per month.
Plaintiffs argue principally that the regulation violates the antidiscrimination provisions of the Americans with Disabilities Act, 42 U.S.C. § 12132, and the Rehabilitation Act, 29 U.S.C. § 794(a), because the reduction in hours will substantially increase the risk that they will be institutionalized in order to receive care adequate to maintain their mental and physical health. The district court denied preliminary relief.
We reverse. We conclude that Plaintiffs have demonstrated a likelihood of irreparable injury because they have shown that reduced access to personal care services will [*3] place them at serious risk of institutionalization. We further conclude that Plaintiffs have raised serious questions going to the merits of their Rehabilitation Act/ADA claims, that the balance of hardships tips sharply in their favor, and that a preliminary injunction will serve the public interest. See Alliance for the Wild Rockies v. Cottrell, 632 F.3d 1127, 1131-32 (9th Cir. 2011). We therefore remand for entry of a preliminary injunction.
I. Background and Procedural History
A. Factual Background
Medicaid is a cooperative federal-state program under which the federal government provides states with financial assistance to supply medical services to low-income people. Arc of Wash. State Inc. v. Braddock, 427 F.3d 615, 617 (9th Cir. 2005). State participation is voluntary, but once a state chooses to participate, the state must submit for federal approval a plan that complies with federal statutory and regulatory requirements. Alexander v. Choate, 469 U.S. 287, 289 n.1, 105 S. Ct. 712, 83 L. Ed. 2d 661 (1985); Townsend v. Quasim, 328 F.3d 511, 514 (9th Cir. 2003). A state plan must cover the cost to eligible people of certain medical services, including inpatient and outpatient hospital care; laboratory and X-ray [*4] services; nursing facility care; and services provided by physicians, dentists, nurse-midwives, and pediatric or family nurse practitioners. See 42 U.S.C. §§ 1396a(a)(10)(A), 1396d(a)(1)-(5), (17), (21); 42 C.F.R. §§ 440.210, 440.220. Within this federal framework, however, states retain "substantial discretion to choose the proper mix of amount, scope, and duration limitations on coverage." Alexander, 469 U.S. at 303; see also Beal v. Doe, 432 U.S. 438, 444, 97 S. Ct. 2366, 53 L. Ed. 2d 464 (1977); 42 C.F.R. § 430.0.
States may, but need not, choose to subsidize other types of medical services, including "personal care services," the benefit at issue here. See 42 U.S.C. §§ 1396a(a)(10)(A), 1396d(a)(24). "Personal care services" are:
services furnished to an individual who is not an inpatient or resident of a hospital, nursing facility, intermediate care facility for the mentally retarded, or institution for mental disease that are
(A). . . authorized for the individual in accordance with a service plan approved by the State,
(B) provided by an individual who is qualified to provide such services and who is not a member of the individual's family, and