## Facts

- The United States sued the State of Mississippi under Title II of the Americans with Disabilities Act and § 504 of the Rehabilitation Act, alleging discrimination against adults with serious mental illness through unnecessary institutionalization and inadequate community services.
- After a federal investigation (2011) and findings letter (2011), Mississippi described reforms but did not reach an agreement; the United States filed suit in 2016.
- The case proceeded to a four-week bench trial on Mississippi’s statewide mental-health system, including state psychiatric hospitals and community-based programs.
- Mississippi maintained community mental health centers and services (including crisis response, intensive community treatment teams, supported housing, supported employment, and peer support), but the court found major gaps in availability, geographic coverage, and effectiveness.
- The court found the system operated in practice as hospital-centered, contributing to repeated or extended hospitalizations for adults with serious mental illness.
- A DOJ clinical review team assessed individuals hospitalized in state facilities and reported that many could benefit from community-based services, generally did not oppose such services, and that community services could be provided at roughly comparable cost.

## Issues

1. Whether Mississippi administered mental-health services for adults with serious mental illness in violation of Title II’s integration mandate by unnecessarily relying on institutional care.
2. Whether adults with serious mental illness were unnecessarily institutionalized where community placement was clinically appropriate, not opposed by the individuals, and reasonably accommodable.
3. Whether Mississippi failed to make reasonable modifications to provide services in the most integrated setting appropriate without showing a fundamental alteration defense.
4. What injunctive relief was warranted to remedy any statewide violations.

## Decision

- The court found Mississippi violated Title II of the ADA and the integration mandate by unnecessarily institutionalizing adults with serious mental illness and failing to provide adequate, effective community-based services.
- The court concluded that the formal existence of community programs did not satisfy federal law where services were not meaningfully accessible or sufficient in practice to prevent unnecessary hospitalization.
- The court credited evidence that many hospitalized individuals were appropriate for community services, generally did not oppose community placement, and could be served in the community within reasonable resource constraints.
- The court ordered broad injunctive relief requiring expansion of key community services and appointed an independent monitor to oversee compliance.

## Legal Principles

- Title II prohibits disability-based discrimination by public entities and requires services to be administered in the most integrated setting appropriate.
- Unjustified institutional isolation of persons with disabilities can constitute discrimination under Title II when community placement is appropriate, not opposed, and can be reasonably accommodated considering available resources and obligations to others.
- Compliance is evaluated by actual operation and accessibility of services, not merely by program design or the existence of services “on paper.”
- A state must make reasonable modifications to avoid unnecessary institutionalization unless it proves the requested changes would fundamentally alter its programs.

## Conclusion

The district court held that Mississippi’s hospital-centered mental-health system, as implemented, resulted in unnecessary institutionalization of adults with serious mental illness in violation of the ADA’s integration mandate, and it imposed structural injunctive relief with ongoing monitoring to expand and make effective statewide community-based services.


United States v. Mississippi, 400 F. Supp. 3d 546 (S.D. Miss. 2019)