A federal appeals court has delivered a sharp rebuke to Florida, concluding that the state is failing some of its most medically fragile children by not providing enough in-home nursing and care coordination. The court record describes a system so strained that families are left with what judges called no real choice but to institutionalize their kids in nursing facilities. One particularly harrowing account in the record describes a baby with a breathing tube who died after pulling out his tracheostomy during a gap in nursing coverage.
The ruling breathes new life into a legal battle that has dragged on for more than a decade between the U.S. Department of Justice and Florida officials over whether the state’s Medicaid policies violate the Americans With Disabilities Act.
As reported by the Miami Herald, the appeals opinion points to court testimony that roughly 139 children currently live in nursing facilities, with about 1,800 more considered at risk of being institutionalized. The Herald also notes that only three nursing homes in the state still operate units for medically complex children, and two of those units are located in Broward County.
The appeals court’s ruling grows out of a July 2023 decision by U.S. District Judge Donald M. Middlebrooks. According to a U.S. Department of Justice court filing, Middlebrooks ordered Florida to ensure that children receive at least 90 percent of the private-duty nursing hours outlined in their care plans and directed the appointment of an independent monitor to oversee compliance. DOJ materials and the district court record describe in often blunt detail the failures in care coordination, persistent staffing gaps and the human fallout that families recounted at trial.
How the Federal Case Began and What It Claims
The Justice Department launched its investigation more than ten years ago and sued Florida in 2013, arguing that the way the state runs Medicaid effectively leaves some medically complex children warehoused in nursing homes instead of living with their families. Reporting from the News Service of Florida and the court record outline a long procedural tug-of-war over whether DOJ even had the authority to bring the case and what kinds of federal remedies would be allowed.
Court filings also spell out what in-home nursing looks like in practice for these children. Florida’s program, according to the record, delivers on average roughly 70 to 80 percent of the private-duty nursing hours that have been authorized, and about a quarter of the children receive less than 60 percent of the hours their care plans call for. The district court concluded that these shortfalls directly contributed to some families opting for institutional placements because they could not count on enough nursing support to safely keep their children at home.
Families and Providers Describe Daily Strain
Care coordinators and parents who testified said their days often revolved around desperately trying to plug holes in the schedule, placing repeated calls to agencies in the hope of filling open shifts. Several witnesses told the court they believed higher reimbursement rates for private-duty nurses would likely help reduce staffing gaps.
Coverage by the Miami Herald highlights parents’ accounts of lost jobs, housing instability and the agonizing decision to move children into nursing facilities when home care broke down. Together, the testimony sketches a picture of families living on the edge, never entirely sure whether the next shift will be covered.
The Legal Framework Behind the Ruling
The federal government’s case rests on the ADA’s integration mandate as interpreted in the Supreme Court’s decision in Olmstead v. L.C. That precedent holds that unnecessary institutionalization of people with disabilities can violate Title II of the ADA. Experts and other witnesses in the Florida case tried to show that when community-based services such as private-duty nursing are medically appropriate, the state must make reasonable accommodations to provide those services in the community. For a summary of the Olmstead standard, see Oyez.
State officials have pushed back, arguing that DOJ is intruding on Florida’s authority to run its own Medicaid program and raising broader federalism concerns. The appeals ruling itself came from a divided panel, a split that suggests the courtroom fight is not over yet. Reporting from the News Service of Florida notes that the state has repeatedly insisted the trial record and evidence do not justify the sweeping remedies ordered by the district court.
For families, the question is far less abstract: will the state bolster and stabilize private-duty nursing so that medically fragile children can actually live at home with the level of support their care plans already authorize? The court record and recent reporting make clear that is what is on the line, and the outcome of the ongoing legal battle will decide whether federal judges can force Florida to move more quickly and more reliably to change how Medicaid serves some of its most vulnerable kids.
