The dispute centers on Florida's Medicaid program for approximately 1,800 medically complex children who require daily medical services including feeding tubes, breathing equipment, and ventilators. The U.S. Department of Justice sued in 2013, alleging that Florida discriminated against these children by failing to provide adequate private duty nursing (PDN) services at home, causing unnecessary institutionalization in nursing facilities. Expert testimony showed that 94% of children received fewer nursing hours than authorized, with many receiving only 70-80% of prescribed care.
Circuit Judge Kevin Jordan wrote that the evidence supported the district court's conclusion that Florida's 'deficit of PDN is causing systemic institutionalization.' The court found that families face impossible choices when nurses don't show up for shifts, forcing parents to miss work or lose jobs to provide care themselves. 'Florida's failure to provide consistent coverage and services forces some families to make the untenable choice between losing income to fill PDN gaps (which as noted may result in eviction) and placing their children in institutions,' Jordan explained.
The case originated as a 2013 Justice Department lawsuit and survived multiple appeals, including a previous trip to the Eleventh Circuit that established the Attorney General's authority to sue under Title II of the ADA. Following a two-week trial in 2023, U.S. District Judge Donald Middlebrooks found Florida violated the Olmstead decision's integration mandate and issued a permanent injunction requiring the state to ensure children receive at least 90% of authorized nursing hours. The Eleventh Circuit had previously stayed portions of the injunction pending appeal.
The ruling establishes that the federal government can seek broad injunctive relief for ADA violations affecting classes of disabled individuals, not just those who filed administrative complaints. Florida must now comply with most aspects of the district court's remedial order, which also requires improved care coordination and transition planning for institutionalized children. The decision could influence similar disability rights enforcement actions nationwide, as six other circuits have recognized claims based on risk of institutionalization while only the Fifth Circuit has rejected such theories.