In the

    United States Court of Appeals
                 For the Seventh Circuit
                     ____________________
No. 19‐1244
KAREN VAUGHN,
                                                   Plaintiff‐Appellee,
                                 v.

JENNIFER WALTHALL, in her official
capacity as Secretary of the
Indiana Family and Social Services
Administration, et al.,
                                             Defendants‐Appellants.
                     ____________________

         Appeal from the United States District Court for the
         Southern District of Indiana, Indianapolis Division.
         No. 16 C 3257 — Jane Magnus‐Stinson, Chief Judge.
                     ____________________

      ARGUED MAY 22, 2020 — DECIDED AUGUST 5, 2020
                ____________________

   Before BAUER, EASTERBROOK, and WOOD, Circuit Judges.
   WOOD, Circuit Judge. Federal law prohibits discrimination
against persons with disabilities, and in furtherance of that
goal, it requires states to administer public programs “in the
most integrated setting appropriate to the needs of qualified
individuals with disabilities.” That duty is bounded by the
2                                                    No. 19‐1244

standard of reasonableness; states are not obligated funda‐
mentally to alter their programs to comply.
     At issue here is whether the anti‐discrimination mandate
compels a state to structure and fund its Medicaid programs
in a manner that ensures that all Medicaid recipients who de‐
sire to receive health care in a home setting may do so regard‐
less of cost to the state. In addition, we must decide how, if at
all, the state’s adoption after oral argument of a pilot program
that provides greater flexibility to those who want home
health care affects this case. We conclude that we still face a
live controversy but that further proceedings are necessary.
We also conclude that the permanent injunction issued by the
district court swept too broadly. If any injunction is still war‐
ranted—a question on which we take no position—it must be
narrowly tailored to any violations that are proven.
                                I
    Karen Vaughn has lived with quadriplegia for approxi‐
mately 40 years and has received home‐based care for over 30
years. She relies on others to help her with all basic daily tasks
and her medical care. She strongly prefers to live at home ra‐
ther than in a nursing facility or other institution. In 2012 she
had a tracheostomy, which is still in place; she uses a ventila‐
tor at night to help her breathe. She must have help with per‐
sonal care (hygiene, dressing, eating, etc.), household mainte‐
nance, mobility exercises, transportation, medications, suc‐
tioning secretions from her tracheostomy, and use of the ven‐
tilator. This amounts to 20+ hours per day of in‐home nursing
care. On occasions when nursing shifts cannot be staffed,
Vaughn has relied on friends to fill the gaps.
No. 19‐1244                                                   3

    Until January 2016, the Indiana Family and Social Services
Administration (FSSA) approved and coordinated Vaughn’s
plan of care, and a state‐approved home‐health agency man‐
aged it day‐to‐day. The state funded her care through two
Medicaid programs for which it receives federal reimburse‐
ment: the core Medicaid program (“prior‐authorization ser‐
vices”), which covered up to 16 hours per day of at‐home
nursing services for Vaughn; and the “Aged and Disabled”
waiver program (“A&D waiver”), which covered additional
hours of non‐medical attendant‐care services, including assis‐
tance with personal hygiene, meal preparation, and house‐
hold tasks. The A&D waiver program is intended to facilitate
care in both home‐ and community‐based settings for those
who otherwise would need to be institutionalized. Under reg‐
ulations in effect at the time, Vaughn had the option to select
her own caregivers and arrange for them to receive A&D
waiver funds. In contrast, she could not personally direct
nursing care funded through the core Medicaid program.
Both nursing staff and attendant‐care providers were paid at
the state’s federally approved Medicaid rates for the particu‐
lar services they performed.
    In January 2016, Vaughn was hospitalized with pneumo‐
nia. That’s when the trouble began. She was cleared by her
doctors to be discharged within a week, but the state could
not find any nurses available to provide the round‐the‐clock
care she needs when she is at home. Matters had changed dra‐
matically while she was in the hospital: the home‐health
agency that had been managing her care could not resume its
services, because it had reassigned its nurses to other clients.
It did so, it said, because it could no longer afford to provide
Vaughn’s care at the low Medicaid reimbursement rates. Over
the next few months, FSSA staff members contacted over 50
4                                                   No. 19‐1244

other home‐health agencies, but none would accept Vaughn
as a client. As a result, she remained in the hospital against
her will.
    In April 2016, Vaughn sent a letter to the FSSA requesting
renewed authorization for a plan of care that included 22
hours per day of nursing services and two hours per day of
attendant care. Given the difficulty the state had experienced
in finding a home‐health agency to manage staffing for her,
Vaughn sought permission to self‐direct all her care, not just
the attendant portion. She proposed that she would directly
hire a case manager, nurses, and other providers, and that the
state would bankroll everything using funds from the Medi‐
caid prior‐authorization program, the Medicaid waiver pro‐
gram, or other public health care programs. The only problem
was that this arrangement was not authorized under Indi‐
ana’s existing regulations. Vaughn also asked to hire “quali‐
fied staff for the level of service I believe most appropriate to
my needs.” In other words, she wanted the ability to hire and
train people who would be paid by the state but who lack the
credentials the state considers necessary to furnish her medi‐
cal care. Vaughn’s doctor and social worker at the hospital
supported her request. They believe that home‐based care de‐
livered by non‐nurses who have been trained to perform
skilled tasks such as those involving her tracheostomy and
ventilator will meet her needs. In the hospital, various medi‐
cal specialists performed these tasks; in Vaughn’s home,
nurses handled them before her hospitalization.
    The FSSA denied Vaughn’s request and instead continued
to search in vain for a home‐health agency that would accept
her as a client. In November 2016 Vaughn was transferred to
a nursing home. She filed a complaint in the district court on
No. 19‐1244                                                  5

November 30, 2016, bringing claims under the Americans
with Disabilities Act (ADA), 42 U.S.C. § 12132; section 504 of
the Rehabilitation Act, 29 U.S.C. § 794; and the reasonable‐
promptness provision of the Medicaid Act, 42 U.S.C.
§ 1396a(a)(8). Meanwhile, time dragged on through 2017 and
the first half of 2018 with no progress. The FSSA continued to
insist that Vaughn’s nursing care be coordinated through a
home‐health agency rather than through self‐direction, but it
was unable to find an agency or combination of agencies will‐
ing to provide her care at Medicaid rates.
    Both parties moved for summary judgment. On June 1,
2018, the district court granted summary judgment in favor of
Vaughn. It followed up on January 9, 2019, with a permanent
injunction requiring the state to “do whatever is necessary to
achieve the result” that Vaughn wanted: round‐the‐clock
home‐based care, fully paid for by the state. On February 8,
2019, in response to a court order requiring it to certify its
compliance with the injunction, the state notified the court
that Vaughn had returned home and that it had allocated state
funds in the amount needed to cover her home‐health and at‐
tendant‐care services. It did so through a unique contract with
Tendercare, a home‐health agency, which agreed to provide
Vaughn’s skilled nursing care at a market rate of $65 per hour.
(This is roughly half again as much as the Medicaid rate of
$43.34.) The state is not authorized to use any federal Medi‐
caid funds to pay Tendercare, because the contract exceeds
the Medicaid cap.
  Indiana now appeals both the summary judgment in
Vaughn’s favor and the permanent injunction.
6                                                     No. 19‐1244

                                II
    We examine the district court’s decision to grant summary
judgment de novo, taking the record in the light most favorable
to the party against whom summary judgment was granted
and drawing all reasonable inferences from the evidence in
that party’s favor. Skyrise Constr. Grp., LLC v. Annex Constr.,
LLC, 

, 955 (7th Cir. 2020). We “consider only what
was before the judge at the summary judgment stage.” Indiana
Funeral Dirs. Ins. Trust v. Benefit Actuaries, Inc., 

,
518 (7th Cir. 2008). “Summary judgment is appropriate when
there are no genuine disputes of material fact and the movant
is entitled to judgment as a matter of law.” Skyrise 

–56.
              A.      ADA and Rehabilitation Act
1. Standard for Liability
    The ADA and the Rehabilitation Act prohibit discrimina‐
tion against qualified persons with disabilities. 42 U.S.C.
§ 12132; 29 U.S.C. § 794(a). For present purposes, there is no
material difference between these two laws, Radaszewski ex rel.
Radaszewski v. Maram, 

, 607 (7th Cir. 2004), and so
in this opinion we generally refer only to the ADA. The law
“explicitly identifie[s] unjustified segregation of persons with
disabilities as a form of discrimination.” Olmstead v. L.C. ex rel.
Zimring, 

, 600 (1999) (internal quotation marks
omitted). Under regulations promulgated by the Attorney
General, when a state chooses to provide services, programs,
or activities for its residents, it must administer the “services,
programs, and activities in the most integrated setting appro‐
priate to the needs of qualified individuals with disabilities.”
No. 19‐1244                                                     7

28 C.F.R. § 35.130(d); see also

state “might vi‐
olate the integration mandate if … through its planning, ser‐
vice system design, funding choices, or service implementa‐
tion practices, [it] promotes or relies upon the segregation of
individuals with disabilities in private facilities or programs.”
Steimel v. Wernert, 

, 911 (7th Cir. 2016) (internal
quotation marks omitted).
    But the integration obligation is not unbounded. In order
to comply with federal law, a state must “make reasonable
modifications in policies, practices, or procedures when the
modifications are necessary to avoid discrimination on the ba‐
sis of disability, unless the public entity can demonstrate that
making the modifications would fundamentally alter the na‐
ture of the service, program, or activity.” 28 C.F.R.
§ 35.130(b)(7)(i) (emphasis added). States are entitled to resist
the latter type of changes. 

.
    States therefore must provide community‐based treat‐
ment for persons with disabilities when: 1) the state’s treat‐
ment professionals determine that such placement is appro‐
priate; 2) the affected persons do not oppose such treatment;
and 3) the placement can reasonably be accommodated, tak‐
ing into account the resources available to the state and the
needs of others with disabilities. 

; see
also 

. In Steimel, we acknowledged that
the third element “represent[ed] the thinking of only a plural‐
ity of the Court,” while the first two commanded a 

–15. Nonetheless, the concurring opinions
made “clear that some version of the ‘reasonable modifica‐
tions’ provision—and its flip side, the fundamental‐alteration
defense—must be taken into account before deciding that the
8                                                  No. 19‐1244

integration mandate was violated.”

Thus, “the ques‐
tion under the ADA is a simple one: what effect will changing
the state’s practices have on the provision of care to the …
disabled, taking into account the resources available to the
state and the need to avoid discrimination?”

Summary Judgment Record
    Despite substantial effort, the FSSA has not been able to
arrange the care Vaughn wants within the constraints of its
Medicaid prior‐authorization and waiver programs. Under
Indiana’s Medicaid program guidelines, Vaughn is eligible
for up to 16 hours per day of reimbursable skilled nursing or
home‐health‐aide services arranged through a home‐health
agency. On a case‐by‐case basis the state may deviate from the
guidelines in order to meet a valid medical need. In the past,
it has approved Vaughn for 20+ hours of skilled nursing per
day. “Skilled providers” include registered nurses, licensed
practical nurses, and home‐health aides, among others. Rele‐
vant to our case, the guidelines classify as “services requiring
skilled care” several things that Vaughn needs, including the
administration of oral medication, urostomy maintenance,
ventilator operation, and tracheostomy suctioning. But the
guidelines do not specify who is authorized to perform “ser‐
vices requiring skilled care” or whether those services are re‐
imbursable with Medicaid funds only when performed by
persons with particular credentials.
   Vaughn is authorized under the A&D waiver program to
receive several hours per day of reimbursable attendant‐care
services, such as assistance with personal care, emptying
urine collection and colostomy bags, mobility, nutrition, and
household tasks. These services are not a substitute for skilled
No. 19‐1244                                                     9

medical care provided by doctors, nurses, or other profession‐
als. The A&D waiver program permits coordination of ser‐
vices by a licensed home‐health or personal‐services agency,
or by “self‐direction,” which is the term used when the client
hires her providers directly and those providers are reim‐
bursed by the state. Whether services are acquired through an
agency or through the client’s self‐direction, all attendant‐
care providers must meet certain state licensure and qualifi‐
cation requirements and be approved by the FSSA. See Ind.
Code § 16‐27‐4‐6; 455 Ind. Admin. Code §§ 2‐6‐1, 2‐6‐2, 2‐6‐3,
2‐11‐1.
    No matter what the service, Medicaid will reimburse only
if “standards of any State licensure or certification require‐
ments are met for services or for individuals furnishing ser‐
vices that are provided.” 42 C.F.R. § 441.302(a)(2); see also 405
Ind. Admin. Code § 5‐29‐1(2) (“Services provided outside the
scope of a provider’s license, registration, certification, or
other authority to practice under state or federal law” are not
covered by Medicaid.).
   After Vaughn was stranded in the nursing home despite
her desire to live at home, she requested several specific ac‐
commodations:
      1)     A baseline of 22 hours per day of prior‐au‐
   thorization services, plus two hours per day of home‐
   maker, attendant care, and other necessary services
   through the A&D waiver.
       2)      The right directly to hire and train qualified
   staff for the level of service she believes most appropri‐
   ate to her needs at competitive, non‐Medicaid‐capped
10                                                   No. 19‐1244

     rates, to cover the hours of service approved in her
     Medicaid care plan.
         3)     Payroll and related services furnished by the
     state (either directly or by contract) to cover the staff
     she hires.
         4)     Waiver of the normal requirements to hire
     either licensed nursing staff or staff employed by a
     Medicaid provider agency.
         5)     Coverage in her authorized care plan of the
     cost of hiring a qualified, professional long‐term care
     case manager of her choosing, at a competitive private
     rate.
    Vaughn’s doctor and social worker supported these re‐
quests and recommended that she return home rather than
remain institutionalized. The state rejected without explana‐
tion all but the first request, and FSSA staff members contin‐
ued the fruitless search for a home‐health agency that would
provide Vaughn’s care at Indiana’s federally approved Med‐
icaid rates. Vaughn argued that the state’s denial of her pro‐
posed accommodations violated the ADA and the Rehabilita‐
tion Act.
   The state insisted that it did not deny Vaughn access to
any programs. Her FSSA‐approved amount of care stayed the
same after her hospitalization in 2016 as before. She remained
in institutions—first the hospital and later the nursing
home—only because there were no qualified providers will‐
ing to work at Medicaid rates. Further, the state contended,
Vaughn’s request to self‐direct her care in its entirety would
constitute a fundamental alteration to existing programs, be‐
No. 19‐1244                                                   11

cause self‐direction was at the time permitted only for at‐
tendant‐care services provided under the A&D waiver pro‐
gram. Skilled nursing care provided as a prior‐authorization
service was not. If she were allowed to self‐direct her nursing
care, it argued, that would create a new service program not
offered to any other Medicaid recipient in Indiana, and “a
State is not obligated to create new services” in order to com‐
ply with the ADA. 

(quoting

).
    The state also protested that allowing Vaughn’s request to
direct her own hiring and care and to waive the requirement
that certain tasks be performed by licensed nurses would be
an unreasonable accommodation. It pointed out that federal
“Medicaid regulations permit a state to establish reasonable
standards relating to the qualifications of providers” and “In‐
diana Medicaid has determined that many of Vaughn’s re‐
quired services are skilled services requiring a medical prac‐
titioner, including management of her tracheostomy, suction‐
ing, management of her ventilator, and administration of her
medications.” Allowing unlicensed personnel to provide
Vaughn’s medical care and receive reimbursement, it said,
would fundamentally alter Indiana’s Medicaid home‐health
programs. (Regulations allow family members or other care‐
givers to provide required care, but they cannot be paid by
the state. Vaughn’s ex‐sister‐in‐law sometimes provided care
to Vaughn when nursing staff were unavailable.)
   Finally, the state argued that Vaughn’s request to pay her
providers at competitive market rates rather than the lower
approved Medicaid rates was a disguised challenge to Indi‐
ana’s Medicaid reimbursement rates. Vaughn did not seri‐
ously challenge this point. In the district court, she criticized
12                                                 No. 19‐1244

the low Medicaid reimbursement rates for nursing care and
attendant care and asserted that she would be able to arrange
care if the state would pay higher rates. The state countered
with a citation to Armstrong v. Exceptional Child Center, Inc.,

(2015). There the Supreme Court held that a
health‐care provider has no private claim against a state on
the theory that the state’s Medicaid reimbursement rates are
too low to ensure an adequate number of providers and level
of care. “The sheer complexity associated with enforcing
§ 30(A), coupled with the express provision of an administra‐
tive remedy, § 1396c, shows that the Medicaid Act precludes
private enforcement of § 30(A) in the 

.
We followed suit in O.B. v. Norwood, 

(7th Cir.
2016), where (citing Armstrong) we declined to “order the
agency to eliminate the shortage [of nurses willing to work at
Medicaid reimbursement rates] by raising those rates.”

    The district court concluded that Vaughn’s proposed
modifications were minor and reasonable and that the state
failed to carry its burden to prove a fundamental alteration. It
saw the state’s refusal to provide Vaughn’s requested accom‐
modations as based on discretionary policy choices about
who could provide certain services and out of what pots of
money those services would be reimbursed, not on legal con‐
straints. The court also thought that it “need not delve into”
the propriety of Vaughn’s challenge to the Medicaid reim‐
bursement rates “because reimbursement rates, adequate or
not, are not determinative as to Ms. Vaughn’s claim.”
3. Reasonableness of Proposed Accommodations
No. 19‐1244                                                    13

    We begin with the question whether Vaughn’s request to
self‐direct her care in its entirety is a reasonable accommoda‐
tion or instead requires a fundamental alteration to Indiana’s
existing Medicaid programs.
    When this case was before the district court, Indiana of‐
fered all eligible Medicaid recipients prior‐approval home‐
care services coordinated through a home‐health agency (i.e.
not self‐directed). It also offered attendant‐care services,
which could be self‐directed, under the A&D waiver pro‐
gram. Vaughn asked the state to modify either the prior‐ap‐
proval program to allow self‐direction, or the A&D waiver
program to allow self‐direction of all services, not just at‐
tendant care. At the time, either request would have provided
Vaughn with a benefit that no other Indiana Medicaid recipi‐
ent received.
    Shortly after oral argument, the landscape changed. Effec‐
tive May 26, 2020, Medicaid allowed Indiana to introduce a
pilot program for self‐directed skilled medical care, available
to Medicaid recipients in two zip codes in the Indianapolis
area. (We refer to this as the Pilot.) We requested supple‐
mental briefs from the parties about the effect of these
changes. Everyone agrees that Vaughn (who lives in one of
the designated zip codes) is eligible for this program. It is pos‐
sible that the Pilot would give her everything she wants as an
accommodation. Aged & Disabled Waiver Program Amend‐
ment, https://www.in.gov/fssa/files/Aged%20and%20Diasa‐
bled‐%20Self%20directed%20care%20amendment.PDF. But
that is not certain: the Pilot uses a formula to cap the budget
available to any recipient. The state’s supplemental brief ex‐
plains that under the Pilot, the FSSA and the care manager
determine the aggregate amount of each participant’s budget
14                                                  No. 19‐1244

by taking the person’s eligible hours and multiplying that by
$41.80 per hour. If Vaughn were to be assigned 24 hours of
Pilot services, her daily budget would be $1,003.20. If that
amount is not enough to elicit the services Vaughn needs, we
could find ourselves right back where we started. That fact,
plus the fact that Vaughn is apparently not at present enrolled
in the Pilot, persuades us that the Pilot has not mooted this
case, and the analysis of the established programs is still im‐
portant.
    The existence of the Pilot underscores the point Indiana
has been making all along: it does not have the unilateral au‐
thority to make the kinds of modifications to its programs
Vaughn wants even if it were so inclined. Both the state’s core
Medicaid program and its waiver programs must be ap‐
proved by the federal Center for Medicare and Medicaid Ser‐
vices (CMS), an entity lodged within the Department of
Health and Human Services. Granting Vaughn’s request to
self‐direct her care plan in its entirety, whether construed as a
modification of the prior‐approval program or the A&D
waiver program, would have required the FSSA to depart
from what CMS has approved for general use. The state ar‐
gued that it could not depart from its approved programs in
the way Vaughn requested and still receive Medicaid reim‐
bursement for the services provided. See 42 C.F.R.
§ 441.360(d) (“[Federal financial participation] for home and
community‐based services … is not available in expenditures
for … [s]ervices that are not included in the approved State
plan and not approved as waiver services by CMS.”).
Vaughn’s requested accommodation, therefore, could be im‐
plemented solely with state funds.
No. 19‐1244                                                   15

    The district court, apparently thinking that some reshuf‐
fling of Medicaid funds was possible, thought that it was rea‐
sonable for Indiana to direct the FSSA to provide whatever
care Vaughn needs. We do not read the law and regulations
that way. Indiana contends, and we agree, that only if the ac‐
commodations comport with federal requirements for Medi‐
caid service approval and funding must it offer them. If, on
the other hand, federal requirements preclude the changes
Vaughn wants, Indiana need not go outside its approved pro‐
grams and relinquish federal reimbursement.
    Vaughn’s second proposed accommodation was to be al‐
lowed to hire staff for the level of service she believes most
appropriate to her needs, regardless of the qualifications the
FSSA or other state regulators believe are necessary to pro‐
vide certain types of care. For example, even though state of‐
ficials believe that tracheostomy maintenance and ventilator
operation should be performed in a home setting by licensed
nurses, Vaughn wants to be able to hire home‐health aides or
other non‐nurses and train them to perform the necessary
tasks. This would alleviate the difficulties stemming from a
nursing shortage in Indiana and likely also would be cheaper
in the long run, because the Medicaid reimbursement rate for
home‐health aides is less than the rate for licensed nurses.
Vaughn’s doctor and social worker support this plan.
   At the summary judgment stage, the state defended its
Medicaid provider qualification standards as a policy choice
entitled to deference, rather than as a legal constraint. This is
significant because it contributed to the district court’s im‐
pression that the state had denied Vaughn’s proposed accom‐
modation as a matter of discretion. Such an exercise of discre‐
16                                                  No. 19‐1244

tion might well be unreasonable given the integration direc‐
tion. Certain provisions of Indiana and federal law allow doc‐
tors and nurses to delegate tasks to other caregivers, includ‐
ing home‐health aides, as long as those caregivers are
properly supervised. See, e.g., Ind. Code § 25‐23‐1‐27.1(b)(6)
(Indiana law on licensing nurses and other health profession‐
als does not prohibit “performance of tasks by persons who
provide health care services which are delegated or ordered
by licensed health professionals, if the delegated or ordered
tasks do not exceed the scope of practice of the licensed health
professionals under Indiana law”);

“registered nursing” as including “delegating tasks which as‐
sist in implementing the nursing … regimen”); 42 C.F.R.
§ 484.80(h)(1)(i) (“If home health aide services are provided to
a patient who is receiving skilled nursing …, a registered
nurse or other appropriate skilled professional who is famil‐
iar with the patient, the patient’s plan of care, and the written
patient care instructions …, must make an onsite visit to the
patient’s home no less frequently than every 14 days.”). In its
summary judgment briefing in the district court, the state left
unanswered the critical question whether any provision of
law requires that only licensed nurses perform the particular
tasks in Vaughn’s care plan.
    If these tasks lawfully can be delegated to a home‐health
aide or other trained caregiver under a nurse’s supervision,
but Indiana simply as a matter of policy prefers that they be
performed by nurses, then Vaughn’s case for an accommoda‐
tion would be stronger—all the more so because her doctor
recommends that Vaughn be allowed to receive treatment at
home rather than in a nursing facility even if that means that
some of her medical care will be provided by trained non‐
nurses. Cf. 

(“If variations in the
No. 19‐1244                                                  17

way services are delivered in different settings were enough
to defeat a demand for more community‐integrated care, then
the integration mandate of the ADA and the Rehabilitation
Act would mean very little.”).
    This means that the central question is whether Vaughn’s
request to employ less‐skilled providers may be granted con‐
sistently with federal requirements for program approval and
funding. We cannot tell on the present record. We do not
know, for example, whether Vaughn’s proposal involves
enough supervision to satisfy the state’s delegation require‐
ments. Nor do we know, under Vaughn’s proposed system,
how many people would have offered their services, and at
what rates of pay. Summary judgment in favor of Vaughn on
this point was thus premature. That is enough to require a re‐
mand, and the impact of the new Pilot also should be exam‐
ined first by the district court, in light of our general com‐
ments about the program.
              B.     Medicaid Act: Promptness
    The Medicaid Act requires that medical assistance pro‐
vided through a state’s Medicaid program “shall be furnished
with reasonable promptness to all eligible individuals.”
42 U.S.C. § 1396a(a)(8). Federal regulations reiterate that this
assistance be furnished “promptly to recipients without any
delay caused by the agency’s administrative procedures.”
42 C.F.R. § 435.930(a).
    Vaughn argues that the state violated her right to reason‐
ably prompt delivery of Medicaid services because, before the
district court’s January 2019 injunction and order, she had
been institutionalized contrary to her wishes for nearly three
years, first in a hospital and then in a nursing home. The state
18                                                  No. 19‐1244

argued that her continued institutionalization was not the re‐
sult of the FSSA’s administrative procedures or intransigence.
Instead, it stemmed from factors beyond the FSSA’s control—
primarily, a lack of licensed nurses willing to provide
Vaughn’s required services at Medicaid rates. Echoing its
ADA analysis, the district court concluded that “Defendants’
own administrative choices—namely, the restrictions they
have imposed on Ms. Vaughn’s home healthcare provision
pursuant to their Medicaid Policy Manual—resulted in their
inability to find a caregiver, or combination of caregivers,
who can provide Ms. Vaughn’s care in a home‐based setting.”
    As we did with respect to Vaughn’s ADA and Rehabilita‐
tion Act claims, we conclude that Indiana’s failure to accom‐
modate Vaughn’s request for a modification to the state’s
Medicaid guidelines was attributable to constraints beyond
its control. The state was not required to carve out a special
category, ineligible for Medicaid funding, for Vaughn. With‐
out proof that the state could achieve Vaughn’s goals in a
manner consistent with federal law, summary judgment was
thus inappropriate on this claim as well.
                               III
    We review the district court’s grant of a permanent injunc‐
tion in Vaughn’s favor for an abuse of discretion; “however,
we review its factual determinations for clear error and its un‐
derlying legal conclusions de novo.” Lacy v. Cook Cnty., 

, 867 (7th Cir. 2018). Permanent injunctive relief is ap‐
propriate if the party seeking the injunction demonstrates “(1)
that it has suffered an irreparable injury; (2) that remedies
available at law, such as monetary damages, are inadequate
to compensate for that injury; (3) that, considering the balance
of hardships between the plaintiff and defendant, a remedy in
No. 19‐1244                                                     19

equity is warranted; and (4) that the public interest would not
be disserved by a permanent injunction.” eBay Inc. v. Mer‐
cExchange, L.L.C., 

, 391 (2006). Since a permanent
injunction is a form of relief on the merits, the plaintiff must
also show not just a probability of success on the merits but
actual success. Winter v. Natural Res. Def. Council, Inc., 

, 32 (2008).
    It would be enough to vacate the permanent injunction
here on the basis of our conclusion that the district court erred
by ruling on the merits in favor of Vaughn. But this case is not
over: Vaughn still needs services, and the Pilot has yet to be
explored. We therefore conclude with a brief discussion of the
permanent injunction the district court entered, in the hope
that we can provide some guidance for any further proceed‐
ings. See Atl. Richfield Co. v. Oil, Chem. & Atomic Workers Int’l
Union, AFL‐CIO, 

, 948 (7th Cir. 1971) (“An injunc‐
tion, though entered on the basis of evidence of past events,
is operative in the future. To the extent that relevant facts are
properly included in the record, we, therefore, consider them
even though they transpired after the entry of the orders be‐
ing reviewed.”)
    As we noted earlier, effective May 26, 2020, Indiana
launched a pilot program under its general A&D waiver. The
Pilot offers Participant Directed Home Care Service (PDHCS)
and covers two zip codes in the Indianapolis area, including
Vaughn’s. Just as Vaughn wanted, it allows participants to se‐
lect, schedule, train, and supervise their own providers and
pay them out of a total budget determined by the FSSA. Par‐
ticipants may hire “either a licensed professional through a
home health agency, an independent, licensed professional,
20                                                    No. 19‐1244

or a non‐clinical competency‐trained unlicensed profes‐
sional” to provide their care, but in exchange for this flexibil‐
ity they “must be willing to accept risks and responsibilities
associated with employing their caregiver and directing their
own care” and “sign a waiver liability form.”
   The parties agree that Vaughn is eligible for this program
and that it incorporates her major proposed modifications to
the earlier program, i.e. it would enable Vaughn to self‐direct
her care in its entirety and to select and train providers of her
own choosing based on her assessment of their necessary
competencies (assuming that the new budget is high enough
to attract willing providers). Thus, the waiver program
amendment appears largely to resolve the disputes in this
case.
    The state emphasizes, however, that the latitude granted
to PDHCS participants is still bounded by other provider‐
qualification standards, which are dictated by federal and
state law and prevailing medical standards and cannot be
waived for a Medicaid recipient. See 42 C.F.R. § 484.75(a)
(“Skilled professional services are authorized, delivered, and
supervised only by health care professionals who meet the
appropriate qualifications specified under § 484.115 and who
practice according to the [home‐health agency’s] policies and
procedures.”);

qualifications for home‐
health aides participating in federal programs);

federal standards for home‐health aides
participating in federal programs); 405 Ind. Admin. Code
§ 5‐29‐1(2) (“Services provided outside the scope of a pro‐
vider’s license, registration, certification, or other authority to
practice under state or federal law” are not covered by Medi‐
caid.).
No. 19‐1244                                                   21

    Federal Medicaid regulations allow home‐health aides to
perform skilled nursing tasks only “as an extension of …
nursing services,” not independently. 42 C.F.R.
§ 484.80(g)(3)(ii). Additionally, federal regulations for the
Medicaid Home and Community‐Based Services waiver pro‐
gram, under which Indiana’s A&D waiver program falls, re‐
quire states to provide CMS with “[a]ssurance that necessary
safeguards have been taken to protect the health and welfare
of the beneficiaries of the services,” including “[a]dequate
standards for all types of providers that provide services un‐
der the waiver” and “[a]ssurance that the standards of any
State licensure or certification requirements are met for ser‐
vices or for individuals furnishing services that are provided
under the waiver.”

provisions appear to impose some limitations on
Vaughn’s ability to select providers without regard to their
formal qualifications and still have the state pay for their ser‐
vices. If non‐nurse caregivers performing medical tasks under
a nurse’s supervision may be reimbursed with Medicaid
funds at appropriate rates, then Vaughn’s request to choose
her own caregivers is reasonable. If, on the other hand, they
cannot be reimbursed by Medicaid, then the accommodation
would be unreasonable, because it would force the state to
bear the full cost of her care. To be clear, an accommodation
that requires the state to provide care at its own expense, out‐
side its federally authorized and reimbursable Medicaid pro‐
grams, is not a reasonable modification of its Medicaid pro‐
grams.
   We take no position here on the way the Pilot fits within
Indiana’s Medicaid programs. We note only that these issues
22                                                   No. 19‐1244

and others may arise if Vaughn chooses to move forward with
a proposal under the Pilot.
                               IV
    We end with some additional comments about our con‐
cerns with the permanent injunction the district court entered
and other issues that may need to be resolved on remand.
First, as we just noted, it is too soon to say whether the in‐
creased flexibility of the Pilot will solve Vaughn’s problems.
Her overall budget will depend on Medicaid caps, and we do
not know at this juncture how far that money will stretch.
    This means that the question whether a Medicaid recipient
has a private right of action to challenge Medicaid rates as too
low to elicit necessary services may come up. Armstrong did
not have to reach this question, as it dealt only with a lawsuit
brought by Medicaid providers. Yet this may be a distinction
without a difference, as we speculated in O.B. 

. On the other hand, it may be significant in light of the fact
that the Armstrong Court discussed, but did not overrule, Wil‐
der v. Virginia Hospital Association, 

(1990) (finding
that the Boren Amendment to the Medicaid Act may be pri‐
vately enforced by health care providers). Since this issue is
as yet unexplored in the present case (because the district
court found it unnecessary to do so), we prefer to save further
consideration for a time when it is necessary.
    Whether or not such a private action exists, another prob‐
lem with the present injunction deserves mention. This case is
about Indiana’s Medicaid program, not its general social‐wel‐
fare regime. It is thus troublesome for the court to issue an
injunction requiring Indiana to furnish Vaughn’s care entirely
out of its own funds, unreimbursed and unsupplemented by
No. 19‐1244                                                 23

Medicaid. Today it is Vaughn, but it easily could be someone
else tomorrow. How much state expenditure outside the
scope of the Medicaid program may a court command? We
could understand this kind of order if one of the conditions of
the Medicaid program itself required this action, but we can‐
not find any such provision in the federal statute or regula‐
tions.
    We say this with great sympathy for people who find
themselves in Vaughn’s situation. Indeed, never have we seen
a time when the advantages of home‐based, community‐inte‐
grated provision of services to the disabled have taken on
greater importance. The New York Times reports that, “[w]hile
8 percent of the country’s [Covid‐19] cases have occurred in
long‐term care facilities, deaths related to Covid‐19 in these
facilities account for more than 42 percent of the country’s
pandemic fatalities.” More Than 40% of U.S. Coronavirus
Deaths Are Linked to Nursing Homes, N.Y. TIMES,
https://www.nytimes.com/interactive/2020/us/coronavirus‐
nursing‐homes.html (last updated July 23, 2020). In Indiana,
where Vaughn lives, 44% of Covid‐19 deaths are linked to
nursing homes. It is entirely understandable that people
strongly prefer to avoid institutional living arrangements.
    Nonetheless, our task is only to determine whether
Vaughn is entitled to the services she has requested under In‐
diana’s version of the Medicaid program. We have concluded
that, as the program was structured before the state adopted
its new pilot program, the answer is no. That means that the
permanent injunction entered by the district court must be va‐
cated.
   Vaughn is entitled to receive at‐home care by providers of
her choosing only to the extent that, working with the state,
24                                                No. 19‐1244

she can craft a program that complies with federal and state
law and does not deprive Indiana of the ability to receive its
share of federal reimbursement through the Medicaid pro‐
gram for services provided. The state is not obligated to reim‐
burse Vaughn’s providers at rates above the approved Medi‐
caid caps, nor must it use funds outside the Medicaid pro‐
gram to comply with a rule about accommodation within the
program.
    For these reasons, we VACATE the order of summary judg‐
ment in favor of Vaughn. In addition, we VACATE the perma‐
nent injunction and REMAND for further proceedings con‐
sistent with this opinion.