The Case Against Accessible Health Care

How Texas v. Kennedy Turns Generations of Underinvestment into a Constitutional Crisis

On January 25, 2026, Texas and 8 other states filed a renewed lawsuit in federal court, now called Texas v. Kennedy, asking a judge to strike down the United States Department of Health and Human Services’ updated rules for Section 504 of the Rehabilitation Act. Co-plaintiffs include Alaska, Florida, Indiana, Kansas, Louisiana, Missouri, Montana and South Dakota.

These states are suing HHS over a 2024 rule that updates how Section 504 is applied to health and human services programs that receive federal money. Section 504 says the federal government, and any program that receives federal financial assistance, may not discriminate against disabled people. The new rule issued in 2024 is the first significant update to HHS’s Section 504 regulations in nearly 50 years.

What this fight is really about

Supporters of the lawsuit describe the rule as an extreme expansion of federal power. Disability rights groups, on the other hand, see a set of basic, overdue expectations for health care and home- and community-based services. Those expectations are tied to the reality that our health systems have been built around a narrow idea of who a “typical” patient is and what kinds of bodies and communication styles count.

The 2024 rule is not a wild new demand. It is a recognition that decades of underinvestment in accessibility, community services and basic tools have real human consequences. It is an attempt to finally bring the law into line with the people who have always been in the waiting room.

The states are in court not because the need is new, but because they are being asked to face the cost of having ignored that need for a very long time.

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What the 2024 Section 504 rule actually does

Section 504 in a sentence

Section 504 of the Rehabilitation Act says that programs and activities that receive federal financial assistance may not discriminate on the basis of disability. In plain language, if you take federal money, you have to serve disabled people on an equal basis and you have to remove barriers that keep them out. This includes many parts of the health system, because federal assistance covers grants, Medicaid and other large streams of funding.

The details of what “nondiscrimination” means live in regulations written by agencies like HHS. HHS last updated its Section 504 regulations in the 1970s. Since then, Congress has passed the Americans with Disabilities Act (ADA), the Supreme Court has decided landmark cases, and health care has changed dramatically.

From vague promises to concrete expectations

In May 2024, HHS issued a final rule titled “Nondiscrimination on the Basis of Disability in Programs or Activities Receiving Federal Financial Assistance.” The rule applies to health and human services programs that receive HHS funds, including hospitals, clinics, nursing homes, home- and community-based service providers, child welfare agencies and others.

The rule does several things that matter for everyday life. It updates regulations that were almost 50 years old so that they reflect the ADA and more recent disability laws. It spells out that covered entities may not discriminate in medical treatment decisions based on stereotypes about disabled people’s quality of life. It makes clear that websites, patient portals and mobile apps must be accessible to disabled users, using modern web standards. It requires accessible medical diagnostic equipment so that people who cannot stand, or who are shorter, or who use wheelchairs, can actually be examined and weighed. It restates and clarifies the obligation to provide effective communication, such as sign language interpreters, captioning and accessible written materials for Deaf, hard of hearing, blind and low-vision patients.

In other words, the rule moves from general principles to specific, practical requirements. It translates “do not discriminate” into “here is what you actually have to do in a modern health system if you want disabled people to be able to use your services.

How this ties to Olmstead and community living

There is another important piece. In 1999, the Supreme Court decided a case called Olmstead v. L.C. under Title II of the ADA. In that decision, the Court held that unnecessarily segregating disabled people in institutions, when they could receive services in the community, can be discrimination. Therefore, states have an obligation to provide services in the most integrated setting that is appropriate, as long as doing so is reasonable and does not fundamentally alter their programs.

Advocates refer to this as the “integration mandate.” The 2024 HHS rule incorporates that idea into Section 504 for health and human services. It recognizes that discrimination can include state policies that place people at serious risk of institutionalization, even if they are not yet in an institution, for example when home- and community-based services are so limited that a nursing facility becomes the only realistic choice.

This connection between Section 504, the ADA and Olmstead is at the heart of the renewed lawsuit. The states are not only challenging technical details. They are attacking the core idea that publicly funded services should be designed to keep people in their homes and communities whenever possible, instead of treating institutions as the default.

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What the rule actually asks of states

Home- and community-based services

On the service side, the 2024 rule strengthens the expectation that states use federal dollars in ways that support community living. Home- and community-based services, often called HCBS, are supports that help people with daily activities like bathing, dressing, cooking, managing medications and getting to appointments so they can live at home rather than in a nursing facility or other institution.

The rule does not give any individual person an unlimited entitlement to services. It does, however, treat systems that routinely underfund or understructure community supports as a civil rights problem when that underinvestment leaves people with no real alternative to institutionalization. It tells states that when they design programs, they must take seriously the obligation to avoid unnecessary segregation and to respond when disabled people are at serious risk of being forced into institutions because community services are not available.

Accessible tools and communication in health care

On the facility side, the rule focuses on the concrete barriers that show up in clinics, hospitals and other health settings. It does not assume a “standard” patient who can see, hear, stand, walk, read small print, process complex information quickly and climb onto high tables. Instead, it asks covered entities to plan for the real range of human bodies and communication needs that walk, roll, or are carried through the door.

That means medical diagnostic equipment that adjusts in height so that shorter people, people with limited strength or flexibility and people who use wheelchairs can be examined safely. It means transfer tools and properly designed beds so that patients and staff are not put at risk of falls and injuries during routine movements. It means communication tools that allow Deaf and hard of hearing patients to understand and be understood, and that allow blind and low-vision patients to access information in formats they can actually use, including accessible websites, portals and digital forms. It means signage that is large enough, clear enough and consistent enough that people can navigate complex facilities without getting lost or overwhelmed.

These changes are not only about people who meet a legal definition of disability. They also make care safer and more usable for older adults, people recovering from surgery, people with temporary injuries, people who are short or tall, people with chronic pain or dizziness, and many others. The 2024 rule simply insists that when federal dollars pay for care, those dollars support systems that work for the population that actually exists.

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What is at stake: Medicaid, Medicare and basic eligibility for funds

Section 504 is enforced in part through the possibility that federal funds can be withheld from programs that discriminate. In practice, enforcement often involves investigation, negotiation and agreements rather than immediate loss of money, but the basic idea is simple. If a program wants to receive federal financial assistance, it must comply with civil rights requirements, including accessibility for disabled people.

This brings us to who is actually affected. Medicaid is the primary health coverage program for many disabled and low-income people, and for many children and adults with complex medical needs. Medicare covers almost everyone over age sixty-five, along with disabled adults under sixty-five who qualify. These are precisely the groups most likely to need accessible equipment, flexibility around mobility and communication, and supports that keep them out of institutions.

When HHS says, through the 2024 rule, that entities receiving its funds must make care usable for disabled people and must avoid policies that push people toward institutions, it is speaking to programs that bill Medicaid and Medicare every day. The rule essentially says: if you accept this money, you need to be able to treat the people whose coverage it represents, and you need to be able to treat all of them safely and equitably.

The lawsuit seeks to weaken or remove that condition. If the states succeed, many programs could continue to receive federal dollars while doing far less to remove barriers and while facing fewer consequences when disabled patients are blocked from care or steered into institutions.

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What the lawsuit reveals

A long history of underinvestment

In a previous version of this case, filed in 2024 as Texas v. Becerra, 17 states went so far as to argue that Section 504 itself was unconstitutional. After strong backlash from disability rights advocates, the coalition narrowed, and the remaining 9 states dropped that particular claim while continuing to challenge the 2024 rule.

The current complaint focuses on the integration mandate, on HHS’s recognition of “serious risk of institutionalization” as a form of discrimination, and on the costs of making systems accessible. The states argue that the rule goes beyond the text of Section 504, conflicts with certain court decisions, and imposes new conditions on federal funding that they did not clearly accept. They claim that complying would strain their budgets and disrupt their Medicaid programs.

Behind these legal theories is a simpler story. For decades, states have underfunded home- and community-based services, have allowed health facilities to function without accessible equipment and communication tools, and have tolerated gaps that leave disabled and aging people with limited options. The 2024 rule does not create those gaps. It shines a light on them and labels them as discrimination when they prevent people from accessing care or from living in the community.

When the states tell the court that the rule is too burdensome or too expensive, they are also admitting that they have not built systems that can meet the needs of the very people their programs are supposed to serve. The burden they describe is, in large part, the cost of catching up. It is the price of decades of decisions in which accessibility and community living were treated as optional extras rather than as basic infrastructure.

The “too expensive” argument, translated

Supporters of the lawsuit frame it as a defense of state budgets and state control. They say HHS is trying to “rewrite” Section 504 and to force states to spend more money than Congress ever required. From the perspective of disabled people and their families, the message lands differently.

When a state says it is too expensive to ensure that patients who cannot stand can receive mammograms, that Deaf patients can understand consent forms, or that people with significant mobility needs can receive care at home rather than only in institutions, it is saying that those people are too costly to plan for. When a state says it is too burdensome to treat a serious risk of institutionalization as a civil rights problem, it is saying that institutions are an acceptable default when budgets are tight.

It is true that the health and long-term care workforce is strained. It is true that home health and HCBS are chronically understaffed and that many direct care workers are underpaid. None of that is a secret. However, those facts point toward the need for investment, training and better pay, not toward the conclusion that disabled people’s rights to access and community living should be narrowed to fit the existing budget.

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A different path: invest in the standard

If the expectations in the 2024 rule feel hard to meet, that is not a reason to lower them. Instead, it is a reason to build the capacity to meet them. A different response from the plaintiff states would begin from a simple set of statements. Medicaid and Medicare beneficiaries deserve safe, accessible care. People who can live in the community with supports should not be forced into institutions because community services are missing. Health facilities should be designed around the range of bodies and communication needs that actually appear in exam rooms, not around a narrow fiction of a “standard” patient.

From there, states could ask for partnership rather than relief from obligations. They could seek federal grants for training programs and vocational degrees in home care, nursing, rehabilitation and interpretation. They could seek higher reimbursement rates tied to wage standards that make direct care jobs livable, which would help recruit and keep staff. They could request capital funding to modernize equipment and information systems so that adjustable tables, accessible diagnostic machines, transfer tools and accessible digital platforms become standard rather than exceptional.

Nothing in that approach would weaken civil rights protections. It would accept that the bar set by Section 504 and the ADA is legitimate and would focus on the practical steps needed to reach it. It would treat disability access and community living as public infrastructure, the same way we treat roads, water systems or broadband, rather than as a special interest.

In short, it would be humane and human-centric rather than about “financial burdens.”

The path chosen in Texas v. Kennedy goes in the other direction. It asks the court to relieve states of part of their responsibility, not to help them meet it. It treats the need itself as the problem.

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Who we decide is worth planning for

At the center of this lawsuit is a basic question. When public money pays for health care and supports, whose bodies and communication needs are these systems built to serve? The 2024 HHS Section 504 rule answers that question clearly. It says that there is no single standard body or brain, that variation in mobility, size, sense perception and cognition is normal, and that publicly funded programs must be designed with that reality in mind. It says that people with disabilities have a right to receive services in their communities when that is possible and appropriate, rather than being pushed into institutions by default.

The 9 states challenging the rule say that these expectations are too burdensome. They do not say that disabled people should be denied care or that institutionalization is always acceptable, not explicitly, but their arguments move the line of responsibility. They shift the focus from “we must build systems that work for you” to “we must not be required to go so far.”

In practice, that shift has a human cost. It leaves more people struggling to access basic care. It leaves more people at risk of avoidable institutionalization. It leaves families and workers carrying the weight of systems that have not been designed with them in mind.

Civil rights laws are often described as abstract guarantees. Section 504 is not abstract. It is about whether a person can enter a clinic, use its equipment, understand its staff, receive care at home, and stay part of a community. When states go to court to limit the reach of those guarantees, they are not only debating statutory text. They are drawing a line around whose lives and whose access are worth the effort and the money.

The 2024 rule does not ask for perfection. It asks for honesty about who uses Medicaid and Medicare and about what it takes to make health care and support services genuinely available to them. To say that even this is too much is not simply a technical complaint. It comes very close to suggesting that people with different mobility or communication needs are not worth investing in. That suggestion is dehumanizing, and it deepens the isolation of people who are already pushed to the edges of public life.

In bringing this lawsuit, these states are admitting to their citizens that they have failed for generations to invest in the needs of those who do fit “the standard,” and now, rather than correcting that historic wrong, they are attempting to justify continuing the practice. At the most extreme, they are denying their citizens the right to the same access others enjoy, despite also being consumers, taxpayers, workers, and citizens. That is the very definition of discrimination, and if they succeed, the legacy of treating differently able individuals as second-class citizens will continue.

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Sources:

• “Texas and Eight Other States Renew Attack on Section 504 and the Right of Disabled People to Live in their Communities.” National Health Law Program, January 28, 2026.

• “Texas v. Kennedy (formerly Texas v. Becerra): What it is and How You Can Help Stop the Attack on Section 504.” Disability Rights Education & Defense Fund January 24, 2025.

• “Texas and Eight Other States Renew Attack on Section 504 and the Right of Disabled People to Live in their Communities.” Center for Public Representation, January 29, 2026.

• “Section 504 of the Rehabilitation Act.” Wikipedia.

• “Olmstead v. L.C.” Wikipedia.

• “Olmstead: Community Integration for Everyone — About Us.” U.S. Department of Justice, ADA.gov.