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STATE OF FLORIDA
IN THE DISTRICT COURT OF APPEAL, FIRST DISTRICT
Case No. : 1D19-1842
L.T. No.: 2018-001072
VARIETY CHILDREN’S HOSPITAL d/b/a
NICKLAUS CHILDREN’S HOSPITAL
Appellant,
vs.
STATE OF FLORIDA, DEPARTMENT OF HEALTH
KENDALL HEALTHCARE GROUP, LTD.,
d/b/a KENDALL REGIONAL MEDICAL CENTER,
THE PUBLIC HEALTH TRUST OF
MIAMI-DADE COUNTY, FLORIDA,
d/b/a JACKSON SOUTH MEDICAL CENTER
Appellees.
APPELLEE’S ANSWER BRIEF
CHRISTOPHER C. KOKORUDA
Assistant Miami-Dade County Attorney
1611 N. W. 12th Avenue
West Wing, Suite 109
Miami, Florida 33136
Florida Bar No. 86501
EUGENE SHY, JR.
Assistant Miami-Dade County Attorney
Florida Bar No. 278653
SUZANNE VILLANO
Assistant Miami-Dade County Attorney
Filing # 98342850 E-Filed 11/04/2019 03:55:48 PM
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Florida Bar No. 19154
Telephone: (305) 585-1313
Facsimile: (305) 326-8239
Primary: [email protected]
Secondary:[email protected]
and
THOMAS F. PANZA, ESQUIRE
PANZA, MAURER & MAYNARD, P.A.
Coastal Towers
2400 E. Commercial Boulevard, Suite 905
Fort Lauderdale, FL 33308
Phone: (954) 390-0100
Fax: (954) 390-7991
By: /s/ Thomas F. Panza
Fla. Bar No. 138551
PAUL C. BUCKLEY, ESQUIRE
Fla. Bar No.906697
ANGELINA M. GONZALEZ, ESQUIRE
Fla. Bar No. 98063
Counsel for The Public Health Trust of
Miami-Dade County, Florida
TABLE OF CONTENTS
TABLE OF AUTHORITIES ....................................................................................... ii
PRELIMINARY STATEMENT ................................................................................ 1
STATEMENT OF THE CASE AND FACTS ............................................................ 2
STANDARD OF REVIEW ......................................................................................... 11
SUMMARY OF THE ARGUMENTS ....................................................................... 13
ARGUMENTS ............................................................................................................. 17
I. The trial court did not err when holding that section 395.4025(16)(c), Florida
Statutes (2018), is not an unconstitutional special law under Article III, Section
10, of the Florida Constitution or Article III, Section 11(a)12, of the Florida
Constitution. ........................................................................................................... 17
a. Section 395.4025(16)(c), Florida Statutes, is a general law as it relates to a
state function and it has a statewide impact ...................................................... 18
i. Section 395.4025(16)(c), Florida Statutes, relates to a state function. ....... 18
ii. Section 395.4025(16)(c), Florida Statutes, has a statewide impact. ........... 23
iii. The “open class” test does not apply to Section 395.4025(16)(c), Florida
Statutes. ....................................................................................................... 31
b. Section 395.4025(16)(c), Florida Statutes, is a general law as it is based on a
permissible classification. .................................................................................. 37
CONCLUSION ............................................................................................................ 46
CERTIFICATE OF SERVICE .................................................................................... 47
CERTIFICATE OF COMPLIANCE ........................................................................... 48
TABLE OF AUTHORITIES
FLORIDA CASES
Bitterman v. Bitterman,
714 So. 2d 356 (Fla. 1998) ................................................................................. 39, 40
Blaesser v. State Bd. of Admin.,
134 So. 3d 1013 (Fla. 1st DCA 2012) .................................................................... 40
Bregar v. Britton,
75 So. 2d 753 (Fla. 1954) ......................................................................................... 40 40
Cantwell v. St. Petersburg Port Authority,
21 So. 2d 139 (Fla. 1945) ................................................................................... 24, 34 24, 34
City of Fort Lauderdale v. Dhar,
185 So. 3d 1232 (Fla. 2016) .............................................................................. 11, 12
Crist v. Ervin,
50 So. 3d 745 (Fla. 2010) ......................................................................................... 12
Coral Springs Street Systems, Inc. v. City of Sunrise,
371 F.3d 1320, 1334 (11th Cir. 2004) ..................................................................... 41
Department of Business Regulation v. Classic Mile, Inc.,
541 So. 2d 1155 (Fla. 1989) ............................................................................... 33, 34
Equity Resources, Inc. v. County of Leon,
643 So.2d 1112 (Fla. 1st DCA 1994) ...................................................................... 40
Francis v. City of Tallahassee,
424 So. 2d 61 (Fla. 1st DCA 1982) ......................................................................... 18
G.G. v. Fla. Dep’t of Law Enforcement,
97 So. 3d 268 (Fla. 1st DCA 2012) ......................................................................... 30
Hartman Transp., Inc. v. Bevis,
293 So. 2d 37 (Fla. 1974) ................................................................................... 16, 43
Hollywood Beach Hotel Co. v. City of Hollywood,
329 So. 2d 10 (Fla. 1976) ........................................................................................ 40
Humana Medical Plan, Inc. v. State, Agency for Health Care Administration,
898 So. 2d 1040 (Fla. 1st DCA 2005) ................................................... 24, 26, 30, 32
Kenz v. Miami-Dade County,
116 So. 3d 461 (Fla. 3d DCA 2013) ........................................................................ 39
Lakeland Regional Medical Center, Inc. v. Agency for Health Care Administration,
917 So. 2d 1024 (Fla. 1st DCA 2006) ......................................................... 43, 44, 45
Lawnwood Medical Center, Inc. v. Seeger,
990 So. 2d 503 (Fla. 2008) ....................................................................................... 18
License Acquisitions, LLC v. Debary Real Estate Holdings, LLC,
155 So. 3d 1137 (Fla. 2014) ................................................................... 12, 32, 33, 34
Moore v. Draper,
57 So. 2d 648 (Fla. 1952) ................................................................................... 12, 20
N. Ridge Gen. Hosp., Inc. v. City of Oakland Park,
374 So. 2d 461, 465 (Fla. 1979)............................................................................... 12
Newman v. Carson,
280 So. 2d 426 (Fla. 1973) ....................................................................................... 12
People ex rel. Barmore v. Robertson,
134 N.E. 815, 817 (Ill. 1922) ................................................................................... 20
R.J. Reynolds Tobacco Co. v. Hall,
67 So. 3d 1084 (Fla. 1st DCA 2011) ....................................................................... 35
Scherer v. Volusia County Dep’t of Corrections,
171 So. 3d 135 (Fla. 1st DCA 2015) ....................................................................... 30
Schrader v. Fla. Keys Aqueduct Authority,
840 So. 2d 1050 (Fla. 2003) .............................. 13, 17, 18, 24, 25, 26, 28, 30, 32, 37
St. Johns River Water Mgmt. v. Deseret Ranches of Fla., Inc.,
421 So. 2d 1067 (Fla. 1982) .......................................... 21, 23, 24, 25, 26, 29, 30, 32
St. Vincent’s Medical Center, Inc. v. Memorial Healthcare Group, Inc.,
967 So. 2d 794 (Fla. 2007) ................................................................................. 35, 36
State ex. rel. Gray v. Stoutamire,
179 So. 730 (Fla. 1938) ............................................................. 21, 22, 32, 33, 37, 41
State ex rel. Landis v. Harris,
163 So. 237 (Fla. 1934) ..................................................................................... 17, 18
Texas Co. v. Town of Miami Springs,
44 So. 2d 808 (Fla. 1950) ......................................................................................... 40
Town of Largo v. Imperial Homes Corp.,
309 So.2d 571 (Fla. 2d DCA 1975) ........................................................................ 40
Venice HMA, LLC d/b/a Venice Reg. Med. Ctr. v. Sarasota Cnty.,
228 So. 3d 76 (Fla. 2017) ....................................................................... 11, 12, 18, 28
FLORIDA STATUTES
§ 252.51, Fla. Stat. (2019) ....................................................................................... 20
§ 395.40, Fla. Stat. (2018) ................................................................................ 3, 4, 19
§ 395.40(1), Fla. Stat. (2018) ................................................................................... 30
§ 395.40(2), Fla. Stat. (2018) ........................................................................ 4, 14, 27
§ 395.40 (3), Fla. Stat. (2018) ................................................................................ 2, 3
§ 395.40(4), Fla. Stat. (2018) ........................................................................... 4, 5, 28
§ 395.4001(7)(a), Fla. Stat. (2018) ............................................................................ 5
§ 395.4001(7)(b), Fla. Stat. (2018) .......................................................................... 29
§ 395.4001(7)(c), Fla. Stat. (2018) .......................................................................... 29
§ 395.4001(15), Fla. Stat. (2018) ............................................................................... 5
§ 395.4001(16), Fla. Stat. (2018) ............................................................................... 3
§ 395.4001(19), Fla. Stat. (2018) ............................................................................. 31
§ 395.401, Fla. Stat. (2018) ...................................................................................... 28
§ 395.402, Fla. Stat. (2017) ........................................................................................ 5
§ 395.402, Fla. Stat. (2018) ...................................................................................... 28
§ 395.402(1)(a)18, Fla. Stat. (2018) .......................................................................... 8
§ 395.402(2)(a), Fla. Stat. (2018) .............................................................................. 8
§ 395.402(4)(a), Fla. Stat. (2017) .............................................................................. 5
§ 395.402(4)(a)(19), Fla. Stat. (2017) ........................................................................ 8
§ 395.4025, Fla. Stat. (2017) .................................................................................. 5, 6
§ 395.4025, Fla. Stat. (2018) ...................................................................................... 4
§ 395.4025(2)(a), Fla. Stat. (2018) ............................................................................ 8
§ 395.4025(2)(d), (5), Fla. Stat. (2017) .................................................................... 6
§ 395.4025(3)-(7), Fla. Stat. (2018) ........................................................................... 8
§ 395.4025(4), (5), Fla. Stat. (2017) .......................................................................... 6
§ 395.4025(8), Fla. Stat. (2018) ................................................................................. 8
§ 395.4025(16), Fla. Stat. ................................................................................. Passim
§ 395.4025(16)(b), Fla. Stat. (2018) .......................................................................... 7
§ 395.4025(16)(c), Fla. Stat. (2018) ................................................................ Passim
§ 395.4045, Fla. Stat. (2018) .................................................................................... 28
§ 395.405, Fla. Stat. (2018) ........................................................................................ 3
§ 569.23(3), Fla. Stat. ............................................................................................... 34
§ 768.28, Fla. Stat. ................................................................................................... 20
LAWS OF FLORIDA
Ch. 77-382, Laws of Fla. ......................................................................................... 25
Ch. 2004-383, Laws of Fla. ..................................................................................... 43
Ch. 2018-66, Laws of Fla. ............................................................................... Passim
FLORIDA CONSTITUTIONAL PROVISIONS
Art. III, § 10, Fla. Const. .................................................................... 2, 13, 17, 28, 46
Art. III, § 11, Fla. Const. .......................................................................................... 18
Art. III, § 11(a)(12), Fla. Const. ......................................................... 2, 13, 18, 28, 46
Art. X, § 12(g), Fla. Const. ...................................................................................... 17
PRELIMINARY STATEMENT
In this Answer Brief, the following abbreviations will be used:
Appellant, Variety Children’s Hospital d/b/a Nicklaus Children’s Hospital,
will be referred to as “NCH.”
Appellee, Florida Department of Health, will be referred to as “the
Department” or “DOH.”
Appellee, Kendall Healthcare Group, Ltd., d/b/a Kendall Regional Medical
Center, will be referred to as “KRMC.”
Appellee, The Public Health Trust of Miami-Dade County, Florida, d/b/a
Jackson South Community Hospital will be referred to as “Jackson South.”
The Record on appeal is referenced as (R. ____) followed by the appropriate
page number(s). Appellant’s Initial Brief is referenced as “IB,” followed by the
appropriate page numbers.
STATEMENT OF THE CASE AND FACTS
In 2018, Florida’s Legislature passed Chapter 2018-66, Laws of Florida (the
“2018 Trauma Law”). The 2018 Trauma Law is a comprehensive general law that
restructures much of the statutory framework regulating Florida’s statewide trauma
system.
NCH is a 309-bed pediatric hospital in Miami-Dade County that operates a
pediatric trauma center. (R. 8, 796.) On May 10, 2018, it filed suit against DOH in
the Leon County Circuit Court for Declaratory and Injunctive Relief. (R. 7.) NCH
alleged that one sub-part, section 395.4025(16)(c), Florida Statutes (2018),1 of the
expansive new trauma bill was an improper special law under Article III, Section
10 and Article III, Section 11(a)(12) of Florida’s Constitution, and therefore,
unconstitutional. (R. 7.) NCH asserted there, and now here, that section (16)(c)
applied only to KRMC, and thereby improperly granted it a special privilege. (R.
7.) Both KRMC and Jackson South were permitted to intervene in the underlying
action. (R. 1006.)
KRMC filed a motion for summary judgment, in which DOH and Jackson
South joined. (R. 559.) Among other contentions, KRMC argued that the new 2018
Trauma Law was not an invalid, special law, and the court should not focus
exclusively, as NCH suggested, on one isolated section, 395.4025(16)(c). KRMC
1 Unless otherwise indicated, references to the Florida Statutes shall be to the 2018
official version published by the Statutory Revision Commission.
argued that the non-severability clause demonstrated the Legislature’s specific
intent that all provisions of this sweeping overhaul of Florida’s trauma system
were joint, integral components of the legislation. In its response, NCH relied on
DOH’s admission that KRMC was the only hospital that met the requirements or
conditions within section 395.4025(16)(c), Florida Statutes. (R. 618.)
Circuit Court Judge Charles Dobson heard summary judgment arguments
from the parties on April 15, 2019, and ultimately ruled that section
395.4025(16)(c), Florida Statutes, was not a special law. He issued an order
granting KRMC’s motion for summary judgment. (R. 1006.) A Final Judgment
was subsequently entered in favor of DOH and the Intervenors, KRMC and
Jackson South. (R. 1025-26.) NCH timely filed a Notice of Appeal. (R. 1028.)
Florida’s Department of Health (“DOH”) is an agency of the State of
Florida. Chapter 395, Florida Statutes, governs the provision of trauma services,
which the Florida Legislature has deemed to be a vital responsibility of the State. §
395.40, Fla. Stat.; § 395.405, Fla. Stat. (granting DOH authority to “adopt and
enforce all rules necessary to administer” the trauma system). Trauma centers treat
patients who sustain injuries caused by trauma. § 395.4001(16), Fla. Stat. DOH’s
mandate is to “promote, protect and improve the health of all people in the state.”
DOH also has the “primary responsibility for the planning and establishment of a
statewide inclusive trauma system,” which includes evaluating and approving
trauma center applications submitted by acute care hospitals. § 395.40(3), Fla.
Stat.; § 395.4025, Fla. Stat. “An ‘inclusive trauma system’ means a system
designed to meet the needs of all injured trauma victims who require care in an
acute-care setting and into which every health care provider or facility with
resources to care for the inured trauma victim is incorporated.” § 395.40(2), Fla.
Stat. The Florida Legislature also recognized that “the benefits of trauma care
provided within an inclusive trauma system to be of vital significance to the
outcome of a trauma victim.” § 395.40(2), Fla. Stat.
Furthermore, Florida’s Legislature highlighted the importance of a robust
trauma program in the first sentence of section 395.40, Fla. Stat.: “The Legislature
finds that there has been a lack of timely access to trauma care due to the state’s
fragmented trauma system.” These pronouncements demonstrate that ongoing
evaluation and improvements to Florida’s trauma network are necessary to achieve
better outcomes for trauma patients. It should be abundantly clear that the
Legislature recognizes that timely access to qualified trauma centers demands
continuing enhancement of the regulatory framework. Section 395.40, Florida
Statutes, also requires various state agencies including DOH, Agency for
Healthcare Administration, Board of Medicine and Board of Nursing to work
together to develop guidelines, standards and rules for the betterment of the trauma
system. “This coordinated approach will provide the necessary continuum of care
for the trauma victim from injury to final hospital discharge.” § 395.40(4), Fla.
Stat.
A “trauma center” is a hospital that has been verified by DOH “to be in
substantial compliance with the requirements in Section 395.4025, Florida
Statutes, and has been approved by DOH to operate as a Level I trauma center,
Level II, or pediatric trauma center.” § 395.4001(15), Fla. Stat. A Level I trauma
center has formal research and education programs, that Level II trauma centers are
not required to have. § 395.4001(7)(a), Fla. Stat. Pediatric trauma centers and
Level I trauma centers are qualified to offer trauma services to injured patients
under age 18. (R. 216.) Level II centers cannot treat pediatric trauma patients (R.
797.)
There are approximately three dozen trauma centers operating in Florida.
(R. 216-217.) Florida’s Legislature had previously enacted laws outlining how
need for new trauma programs was to be identified in a particular area through an
allocation system of Trauma Service Areas (“TSAs”). § 395.402; 395.4025, Fla.
Stat. (2017). The State’s 67 counties were assigned to 19 TSAs for purposes of
managing the trauma system. §395.402(4)(a), Fla. Stat. (2017). Under those
provisions, DOH was required, by administrative rule, to calculate and publish
each year the number of trauma centers to be allocated for each TSA across the
state.
The previous statute, section 395.4025, Florida Statues (2017), outlined a
21-month application and review process for Florida hospitals seeking to become
designated as a trauma center. Under that regulatory scheme, DOH required trauma
programs to begin operations, under a provisional approval, once DOH determined
an application was complete and in substantial compliance with the critical
elements. DOH would not conduct a site visit until after the trauma center was
operational. § 395.4025 (2)(d), (5), Fla. Stat. (2017). The in-depth review
conducted by DOH included onsite evaluation by out-of-state experts and a more
complete evaluation of the paper application and overall program. § 395.4025(4),
(5), Fla. Stat. (2017). Among other measures, the 2018 Trauma Law overhauled
the trauma center application and approval process, even though there were a
number of trauma programs that were pending final verification under the prior
statutory application process. (R. 228-29, 733.)
KRMC is an acute-care hospital located in Miami-Dade County that had
been operating as a Level II trauma center since 2011. (R. 10, 27.) KRMC
submitted an application in 2016 – under the previous statutory application
guidelines - to obtain approval from DOH to become a Level I trauma program.
(R. 250.) KRMC’s paper application to transition to a Level I center satisfied the
necessary critical elements. (R. 233, 735.) Those elements are incorporated in
Florida’s Trauma Center Standards. (DH pamphlet 150-9). (R. 236.) Therefore,
DOH provisionally approved KRMC to operate as a Level I trauma center. (R.
234-235, 735.) NCH timely filed an administrative challenge to KRMC’s
designation as a provisionally approved Level I trauma program. (R. 231.)
KRMC also passed DOH’s former in-depth review process by September
2016 (R. 230, 737.) It successfully completed a site survey in June 2017 (R. 231.)
By July 5, 2017, KRMC had satisfied all DOH requirements to be approved as a
Level I trauma center (R. 238.) KRMC was notified by DOH on March 22, 2018
that it had been verified as a Level I trauma center, pursuant to the 2018 Trauma
Law. § 395.4025(16)(c), Fla. Stat. (R. 240.)
Jackson South is a public, non-profit acute-care hospital in Miami-Dade
County that owns and operates a Level II trauma program. (R. 22.) DOH verified
Jackson South’s Level II trauma program pursuant to section 395.4025(16)(b),
Florida Statutes, as enacted in the 2018 Trauma Law. (R. 22.)
The 2018 Trauma Law includes many other changes to the framework
regulating Florida’s trauma system. It reclassified the number of trauma centers
allocated across the state into 18 TSAs, replacing the previous process in which
DOH determined the number of trauma centers needed in a particular TSA. Ch.
2018-66, § 5, Laws of Fla. The 2018 law provides new criteria outlining when
additional trauma centers can be opened. Ch. 2018-66, § 6, Laws of Fla.
Prior to 2018, KRMC, NCH, and Jackson South were in TSA 19, which
encompassed Monroe and Miami-Dade Counties. § 395.402(4)(a)(19), Fla. Stat.
(2017). TSA 19 was re-classified under the new law in 2018 as TSA 18. §
395.402(1)(a)18, Fla. Stat. (2018).
The 2018 Trauma Law, including Section 395.4025, sub-parts (3) through
(7), Florida Statutes, outlines a categorically different application and review
process for an acute care hospital seeking to become a verified trauma center in
Florida. Moreover, 395.4025(8), Florida Statutes, creates new requirements for
protesting DOH’s decisions regarding whether a trauma center application should
be approved or whether a need has been established.
The Florida Legislature directed DOH, through the new law, to prepare an
analysis of the statewide trauma system in 2020 and every three years thereafter. §
395.4025(2)(a), Fla. Stat.
The new legislation also creates an advisory council, comprised of subject-
matter experts and stakeholders, to help DOH develop a more inclusive trauma
system. The advisory group’s purpose is “to promote an inclusive trauma system
and enhance cooperation among the trauma system stakeholders. § 395.402(2)(a),
Fla. Stat.
More importantly, section 395.4025(16), Florida Statutes, and its numerous
sub-parts, outlined and clarified the licensure status of all 35 operational trauma
centers that existed at the time the law was enacted. (R. 252.) Specifically, the
Legislature included the following provisions to address the status of all levels of
trauma centers in the state in Section 395.4025(16), Florida Statutes:
(a) Notwithstanding the statutory capacity limits
established in s. 395.402(1), the provisions of subsection
(8), or any other provision of this part, an adult Level I
trauma center, and adult Level II trauma center, a Level
II trauma center with a pediatric trauma center, a jointly
certified pediatric trauma center, or a stand-alone
pediatric trauma center that was verified by the
department before December 15, 2017, is deemed to have
met the trauma center application and operational
requirements of this section and must be verified and
designated as a trauma center.
(b) Notwithstanding the statutory capacity limits
established in s. 395.4025(1), the provisions of
subsection (8), or any other provision of this part, a
trauma center that was not verified by the department
before December 15, 2017, but that was provisionally
approved by the department to be in substantial
compliance with Level II trauma standards before
January 1, 2017, and is operating as a Level II trauma
center, is deemed to have met the application and
operational requirements of this section for a trauma
center and must be verified and designated as a Level II
trauma center.
(c) Notwithstanding the statutory capacity limits
established in s. 395.402(1), the provisions of
subsection (8), or any other provision of this part, a
trauma center that was not verified by the
department before December 15, 2017, as a Level I
trauma center but that was provisionally approved by
the department to be in substantial compliance with
Level I trauma standards before January 1, 2017, and
is operating as a Level I trauma center is deemed to
have met the application and operational
requirements of this section for a trauma center and
must be verified and designated as a Level I trauma
center.
(d) Notwithstanding the statutory capacity limits
established in s. 395.402(1), the provisions of subsection
(8), or any other provision of this part, a trauma center
that was not verified by the department before December
15, 2017, as a pediatric trauma center but was
provisionally approved by the department to be in
substantial compliance with the pediatric trauma
standards established by rule before January 1, 2018, and
is operating as a pediatric trauma center is deemed to
have met the application and operational requirements of
this section for a pediatric trauma center and, upon
successful completion of the in-depth and site review
process, shall be verified and designated as a pediatric
trauma center. Notwithstanding subsection (8), no
existing trauma center in the same trauma service area or
in a trauma service area contiguous to the trauma service
area where the applicant is located may protest the in-
depth review, site survey, or verification decision of the
department regarding an applicant that meets the
requirements of this paragraph.
(e) Notwithstanding the statutory capacity limits
established in s. 395.402(1), or any other provision of
this part, a hospital operating as a Level II trauma center
after January 1, 2017, must be designated and verified by
the department as a Level II center if all of the following
apply…
(f) Notwithstanding the statutory capacity limits
established in s. 395.402(1), or any other provision of
this act, a joint pediatric trauma center involving a Level
II trauma center and a specialty licensed children’s
hospital which was verified by the department before
December 15, 2017, is deemed to have met the
application and operational requirements of this section
for a pediatric trauma center and shall be verified and
designated as a pediatric trauma center even if the joint
program is dissolved upon the expiration of the existing
certificate and the pediatric trauma center continues
operations independently through the specialty licensed
children’s hospital, provided that the pediatric trauma
center meets all requirements for verification by the
department.
§ 395.4025(16), Fla. Stat. (2018).
Finally, and importantly, the Legislature included a Non-Severability clause
in the 2018 Trauma Law to ensure that it is treated as intended, that is, as an
interconnected whole:
If the provision of this act relating to s. 395.4025(16),
Florida Statutes, are held to be invalid or inoperable for
any reason, the remaining provisions of this act shall be
deemed to be void and of no effect, it being the
legislative intent that this act as a whole would not have
been adopted had any provision of the act not been
included.
Ch. 2018-66, § 14, Laws of Fla.
STANDARD OF REVIEW
The purpose of this appeal is to ascertain whether section 395.4025(16)(c),
Florida Statutes, comports with the constitutional requirements of a general law.
The courts in Florida have routinely held that “[t]he constitutionality of a statute is
a pure question of law subject to de novo review.” Venice HMA, LLC v. Sarasota
Cnty., 228 So. 3d 76, 79 (Fla. 2017) (quoting City of Fort Lauderdale v. Dhar, 185
So. 3d 1232, 1234 (Fla. 2016)). Notably, “as in all constitutional challenges, the
statute comes to the Court clothed with the presumption of correctness and all
reasonable doubts about the statute’s validity must be resolved in favor of
constitutionality.” Dhar, 185 So. 3d at 1234; Crist v. Ervin, 50 So. 3d 745, 747
(Fla. 2010); Venice HMA, LLC., 228 So. 3d at 79. The Florida Supreme Court has
also held that the party “who assails the classification has the burden of showing
that it is arbitrary and unreasonable.” License Acquisitions, LLC v. Debary Real
Estate Holdings, LLC, 155 So. 3d 1137, 1149 (Fla. 2014) (quoting N. Ridge Gen.
Hosp., Inc. v. City of Oakland Park, 374 So. 2d 461, 465 (Fla. 1979)).
Moreover, the Court must consider in this proceeding that the statute at issue
was drafted by the Florida Legislature pursuant to its inherent power to ensure the
health, safety, and welfare of its citizenry. As noted, supra, the trauma system in
the State of Florida provides care for the most critically injured patients in our
state. Therefore, “[a]ll reasonable presumptions should be indulged in favor of the
validity of the action of the legislature” when taken in order to protect public
health. Moore v. Draper, 57 So. 2d 648, 650 (Fla. 1952); Newman v. Carson, 280
So. 2d 426, 428 (Fla. 1973). This is because “[a]mong all the objects sought to be
secured by governmental laws none is more important than the preservation of
public health.” Moore, 57 So. 2d at 649. Thus, the trauma bill should be reviewed
with both a strong presumption of correctness and recognition of its high
importance in the regulation of public health.
SUMMARY OF THE ARGUMENTS
The trial court was correct in holding that section 395.4025(16)(c), Florida
Statutes, is a valid general law that does not violate Article III, Section 10 or
Article III, Section 11(a)(12) of the Florida Constitution. A general law is one that
“operates universally throughout the state, or uniformly upon subjects as they may
exist throughout the state, or uniformly within permissible classifications by
population of counties or otherwise, or is a law relating to a state function or
instrumentality.” Schrader v. Fla. Keys Aqueduct Authority, 840 So. 2d 1050, 1055
(Fla. 2003).
Section 395.4025(16)(c), Florida Statutes, is a general law because it relates
to a state function and it has a statewide impact. As part of its state function, the
Florida Legislature is responsible for creating and structuring the trauma system in
the state. Part II of Chapter 395, Florida Statutes, contains the statutory provisions
that govern the trauma system. Administering the trauma system is one of the
State’s most critical responsibilities as it protects the public health and safety of its
citizens and visitors.
The 2018 Trauma Law was passed as a wide-ranging legislative act that
restructured a comprehensive statewide plan, the trauma system. As part of that
reform, the Florida Legislature clarified the licensure status of all the operational
trauma programs in the state. This ensured that there was no confusion as to what
trauma programs could continue to provide trauma care to critically injured
patients in their communities. Guaranteeing that the citizenry has access to trauma
care and emergency services are inherent state functions. Accordingly, the fact that
the Legislature’s governance over the trauma system is a state function clearly
supports the trial court’s proper conclusion that section 395.4025(16)(c), Florida
Statutes, is a general law. NCH has failed to appreciate this critical distinction,
which undermines the merit of its arguments.
Additionally, section 395.4025(16)(c), Florida Statutes, has a statewide
impact. The trauma system is an interconnected network of health care providers
and facilities that provide care to the most critically injured patients in the State of
Florida. The Legislature itself has codified the vital nature of the Trauma System
in Section 395.40(2), Florida Statutes, by stating “[t]he Legislature finds it
necessary to plan for and establish an inclusive trauma system to meet the needs of
trauma victims.” Although section 395.4025(16)(c), Florida Statutes, has limited
applicability, its impact is felt throughout the trauma system and, therefore, the
state. Pursuant to section 395.4025(16)(c), Florida Statutes, KRMC’s Level I
trauma program was verified. This allows patients to continue to have increased
access to a higher level of trauma care in the trauma service area and it provides an
additional Level I resource for other trauma programs, including Level II and
pediatric trauma programs, throughout the state.
Since section 395.4025(16)(c), Florida Statutes, relates to a state function
and has a statewide impact, it does not have to meet the open class requirement
that other, non-state function related, laws must meet. This is another important
distinction that NCH has failed to ascertain in this appeal.
Alternatively, section 395.4025(16)(c), Florida Statutes, is a valid, general
law because it operates uniformly within a permissible classification. The
classification used in section 395.4025(16)(c), Florida Statutes, is necessary as it
ensures that the statute does not interfere with KRMC’s vested rights.
At the time that the Florida Legislature was considering how to restructure
the trauma program, KRMC had already completed and passed all of the necessary
steps to attain verification for its Level I trauma program. There was nothing left
for KRMC to do, as part of the application process, to become a verified program.
Accordingly, KRMC had a vested substantive right in its trauma program’s Level I
verification.
Section 395.4025(16), Florida Statutes, identifies the trauma programs that
were in existence, either through provisional approval or verification, at the time
that the 2018 Trauma Law was enacted. Section 395.4025(16)(c), Florida Statutes,
in particular, identifies the Level I trauma programs that were provisionally
approved in the State of Florida and were already providing services to the
community. Although KRMC is the only program that Section 395.4025(16)(c),
Florida Statutes, applied to, that is only because there were no other provisionally
approved Level I trauma programs in the State of Florida at that time. Accordingly,
section 395.4025(16)(c), Florida Statutes, applies uniformly to the existing
provisional Level I trauma programs at the time that the 2018 Trauma Law was
enacted.
When enacting the 2018 Trauma Law, the Legislature did not create a new
right for KRMC in section 395.4025(16)(c), Florida Statutes. Instead, the
Legislature used a grandfather clause, which is a permissible tool in statutory
construction, to protect KRMC’s vested right in its Level I trauma program
verification. This is legally acceptable as the Florida Supreme Court has previously
held that grandfather clauses are favored in the law “because they tend to protect
rights either existing or in the process of being obtained prior to cut-off dates.”
Hartman Transp., Inc. v. Bevis, 293 So. 2d 37 (Fla. 1974). In summary, the
Legislature used a proper classification, through a grandfathering clause, that was
uniformly applied, to designate KRMC as a verified Level I trauma program, since
KRMC had already met all the necessary requirements for verification.
Although NCH continues to argue in this appeal that section
395.4025(16)(c), Florida Statutes, is an invalid, special law, this argument lacks
merit. When section 395.4025(16)(c), Florida Statutes, is analyzed based on its
state function, statewide impact, and/or its proper classification, it is clear that it is
a valid, general law. Due to this, this Court should hold that section
395.4025(16)(c), Florida Statutes, is a general law and that the trial court’s Final
Judgment in this case should be affirmed.
ARGUMENTS
I. The trial court did not err when holding that section 395.4025(16)(c),
Florida Statutes (2018), is not an unconstitutional special law under
Article III, Section 10, of the Florida Constitution or Article III, Section
11(a)12, of the Florida Constitution.
Article III, section 10, of the Florida Constitution states, in part, that “[n]o
special law shall be passed unless notice of intention to seek enactment thereof has
been published in the manner provided by general law.” The term “special law” is
defined in the Florida Constitution as “a special law or local law.” Art. X, § 12(g),
Fla. Const. However, the Florida Supreme Court has further defined “special laws”
and “general laws” as follows:
[A] special law is one relating to, or designed to operate
upon, particular persons or things, or one that purports to
operate upon classified persons or things when
classification is not permissible or the classification
adopted is illegal; a local law is one relating to, or
designed to operate only in, a specifically indicated part
of the state, or one that purports to operate within
classified territory when classification is not permissible
or the classification adopted is illegal.
A general law operates universally throughout the state,
or uniformly upon subjects as they may exist through the
state, or uniformly within permissible classifications by
population of counties or otherwise, or is a law relating to
a state function or instrumentality.
Schrader v. Fla. Keys Aqueduct Authority, 840 So. 2d 1050, 1055 (Fla. 2003)
(quoting State ex rel. Landis v. Harris, 163 So. 237, 240 (Fla. 1934)).
The Florida Constitution also lists a number of prohibited special laws that
cannot be enacted by the Florida Legislature under any circumstance. Art. III, § 11,
Fla. Const. Among the prohibited laws are any special laws pertaining to “private
incorporation or grant of privilege to a private corporation.” Art. III, § 11(a)(12),
Fla. Const. The Florida Supreme Court has defined the term “privilege” in this
section as “having something that others do not have.” Venice HMA, LLC d/b/a
Venice Regional Medical Center v. Sarasota County, 228 So. 3d 76, 81 (Fla.
2017); see also Lawnwood Medical Center, Inc. v. Seeger, 990 So. 2d 503, 511
(Fla. 2008).
a. Section 395.4025(16)(c), Florida Statutes, is a General Law as it Relates to a
State Function and it has a Statewide Impact.
i. Section 395.4025(16)(c), Florida Statutes, relates to a State Function.
A law that relates to a state function or instrumentality is a general law. “A
nonexclusive list of such traditional [state] functions included police protection,
sanitation, public health, parks and recreation, hospitals, and schools.” Francis v.
City of Tallahassee, 424 So. 2d 61, 62 (Fla. 1st DCA 1982). The trauma system,
which is at issue in this matter, plays a central role in providing emergency medical
care to the most critically injured residents and visitors within the State of Florida.
In NCH’s ongoing challenge to KRMC’s Level I trauma program verification, it
has completely overlooked the fact that section 395.4025(16)(c), Florida Statutes,
is a law that relates to a state function or instrumentality and is, therefore, a general
law.
As part of its state function, the Florida Legislature is responsible for
creating and structuring the trauma system in the state. Part II of Chapter 395,
Florida Statutes, contains the statutory provisions that govern the trauma system.
The first statute in Part II of Chapter 395, Florida Statutes, sets out the legislative
findings and intent for the statutory framework of the trauma system. § 395.40, Fla.
Stat. In this statute, the Legislature states that “it is necessary to plan for and
establish an inclusive trauma system to meet the needs for trauma victims.” Id. The
Legislature goes on to define “inclusive trauma system” as “a system designed to
meet the needs of all injured trauma victims who require care in an acute-care
setting and into which every health care provider or facility with resources to care
for the injured trauma victim is incorporated.” Id. Importantly, the Legislature also
“deems the benefits of trauma care provided within an inclusive trauma system to
be of vital significance to the outcome of a trauma victim.” Id. In essence, the
Legislature asserts in this section that the regulation of trauma services is one of
the State’s most critical responsibilities as it relates to protecting its citizens and
visitors.
The Florida Supreme Court, quoting the United States Supreme Court,
stressed the state’s inherent responsibility in protecting public health with the
following:
That the preservation of the public health is one of the
duties devolving upon the state as a sovereign power will
not be questioned. Among all the objects sought to be
secured by governmental laws none is more important
than the preservation of public health. The duty to
preserve the public health finds ample support in the
police power, which is inherent in the state, and which
the state cannot surrender.
Moore v. Draper, 57 So. 2d 648, 649 (Fla. 1952) (quoting People ex rel. Barmore
v. Robertson, 134 N.E. 815, 817 (Ill. 1922)).
However, the trauma system’s state function is not only limited to its role in
protecting public health, it also includes the fact that it assists individuals in
emergency situations. This is important to note because providing assistance in
emergency situations is also a critical component of the state’s function. This is
evidenced by legislative actions taken by the Florida Legislature, including the
enactment of a statute that provides sovereign immunity to those private
individuals or entities who provide shelter during an actual, impending, mock, or
practice emergency. See § 252.51, Fla. Stat. (2019) (“Any such person or
organization who provides such [emergency] shelter for compensation shall be
deemed to be an instrumentality of the state or its applicable agency or subdivision
for the purposes of s. 768.28.”). While that statute is not directly applicable to the
trauma system, it underscores the Legislature’s understanding of what constitutes a
state function or instrumentality.
The fact that the Legislature’s governance over the trauma system is a state
function clearly supports the trial court’s proper conclusion that section
395.4025(16)(c), Florida Statutes, is a general law. The Florida Supreme Court has
explicitly held the following:
The terms ‘special or local laws’ as used in the
Constitution refer ordinarily to laws relating to entities,
interests, rights, and functions other than those of the
State, since the organic law does not contemplate or
require previous publication of notice of proposed laws
for the establishment of counties and of courts authorized
by the Constitution, fixing the terms of courts to the
State, the creation of offices, the disposition of State
funds and property, and many other attributes of the
sovereignty.
State ex. rel. Gray v. Stoutamire, 179 So. 730, 733-34 (Fla. 1938) (emphasis
added); St. Johns River Water Mgmt. Dist. v. Deseret Ranches of Fla. Inc., 421 So.
2d 1067 (Fla. 1982). In Stoutamire, the Court further held that both special laws
and local laws are exempt from notice requirements if they relate to a state
function:
In cases where ‘special or local laws’ are forbidden or
where notices of proposed laws which may be special or
local laws have not been duly published, such laws are
legally inoperative, unless they may be duly adjudged to
be general laws, because they are based on a proper
classification or because they relate to State agencies,
functions, or properties, or for other reasons under the
Constitution.
179 So. at 734. NCH has failed to appreciate the critical distinction identified in
Stoutamire that laws related to state functions are general laws even if they have
limited applicability.
Every section in the 2018 Trauma Law relates to a state function since it
addresses the structure and operation of Florida’s trauma system. More
specifically, Section 395.4095(16), Florida Statutes, identifies, by class, all the
trauma programs that are currently operational and clarifies their licensure status.
This is critically important as the 2018 Trauma Law revamps the structure and
operation of the trauma system, including how trauma programs are to be verified
in the future. Not all trauma centers operating when the bill was passed were in the
same position relative to the Department’s process of review and ultimate
approval. Thus, without the clarification contained in Section 395.4095(16),
Florida Statutes, there would be confusion as to whether certain trauma programs
that were already operational, and accepting patients, would be permitted to
continue to do so in the future. This uncertainty is less than ideal with any
governmental system, but it would be even more concerning for this uncertainty to
exist in the governmental system that is tasked with ensuring that critically injured
patients have timely access to emergency care.
Section 395.4025(16)(c), Florida Statutes, itself clarifies that the
provisionally approved Level I trauma programs in the State of Florida that had
already satisfied the Trauma Standards could continue operating and attain
verification. This classification only applied to KRMC because it was the only
operational provisional Level I trauma program in the state, no other program had
applied for this designation in the two years prior to the enactment of the 2018
Trauma Law. (R. 251.) Every operational Level I trauma program in the State of
Florida is a vital piece of the State’s overall trauma system, including KRMC. It
was within the Legislature’s discretion and function to identify whether KRMC’s
Level I trauma program should continue to act as a state instrumentality within the
trauma system and once that choice was made, it fell squarely within the definition
of a general law. Accordingly, since section 395.4025(16)(c), Florida Statute,
relates to a state function or instrumentality, NCH’s argument is meritless and the
trial court’s Final Judgment in this case should be affirmed.
ii. Section 395.4025(16)(c), Florida Statutes, has a Statewide Impact.
The Florida Supreme Court has “repeatedly held that a law does not have to
be universal in application to be a general law if it materially affects the people of
the state.” St. Johns River Water Mgmt. Dist. v. Deseret Ranches of Fla., Inc., 421
So. 2d 1067, 1069 (Fla. 1982). A law that has a limited application can be
considered a general law if it was enacted as part of a comprehensive state plan and
its impact is interrelated with or contributes to a statewide program. Id.; Schrader
v. Fla. Keys Aqueduct Authority, 840 So. 2d 1050 (Fla. 2003); Humana Medical
Plan, Inc. v. State, Agency for Health Care Admin., 898 So. 2d 1040, 1045 (Fla. 1st
DCA 2005); Cantwell v. St. Petersburg Port Authority, 21 So. 2d 139, 140 (Fla.
1945). Although this analysis can be separate and apart from the analysis done
when a law relates to a state function, it can also bolster the state function analysis
and lend further support that the law is a general one when it has a statewide
impact as well. St. Johns, 421 So. 2d at 1070-71; Schrader, 840 So. 2d at 1056-57;
Humana, 898 So. 2d at 1044-45.
In St. Johns, the Florida Supreme Court held that the challenged law creating
the Greater St. Johns River Basin was a constitutional, properly enacted general
law, reversing the Fifth District Court of Appeal’s opinion holding to the contrary.
At the start of its analysis, the Florida Supreme Court stated that the challenged
law “was enacted as an amendment to chapter 373, Florida Statutes, and [the
Court] must construe it in conjunction with that chapter.” St. Johns, 421 So. 2d at
1068. The Court then explains that chapter 373, “The Florida Water Resources
Act,” provides a comprehensive statewide plan for the oversight, management, and
protection of the state waters. Id. The Act, when it was originally enacted in 1972,
provided for the creation of five water management districts and allowed for the
creation of sub-districts of basins. Id. Subsequently, in 1976, the Legislature
created several districts and basins that were in existence at the time that the
challenged law was enacted in 1977. Although the challenged law created a single
basin, the Greater St. John River Basin, the Court held that there was “no
reasonable basis for characterizing its enacting legislation any differently than the
legislation creating the other basin.” Id. at 1068-69. The Court then went on to
explain that “[a]lthough enacted in different years and applicable to different areas
of the state, both laws became integral parts of Florida’s comprehensive water
management plan affecting people statewide.” Id. at 1069. Based on this analysis,
the Court held that “[b]ecause of the statewide impact of the Water Resources Act
and because of the contribution made by each and every water management district
and basin to the overall water management plan, we hold that chapter 77-382 is a
general law properly enacted by the Florida Legislature.” Id.
In Schrader, the Florida Supreme Court considered the constitutionality of a
statute that authorized the local government in a single county, designated as being
an “area of critical concern,” to impose more stringent wastewater ordinances than
in other areas. Although the challenged statute had limited applicability, the Court
found that “the section of the statute being challenged is part of a general statutory
scheme to environmentally protect areas which have been legislatively designated
as being of ‘critical state concern.’” Schrader, 840 So. 2d at 1056. The Court also
accepted “that the primary purpose of this statute is one of statewide importance
and impact.” Id. As part of its analysis, the Court identified the nearshore waters
of the Florida Keys as a natural resource of statewide importance due to its
designation as an area of critical state concern and “by its direct relationship with
industries of statewide importance such as tourism and seafood.” Id. Accordingly,
the Court held that the challenged statute was a general law since it related to a
state function and that it should be “considered in the larger context of a
comprehensive state plan.” Id. at 1056-57.
Similarly, in Humana, the First District Court of Appeal found that a statute
reforming the state’s Medicaid program was not a special law, but was a
constitutional general law, because its primary purpose was to improve the overall
program of Medicaid throughout the state even though that law applied only to
Miami-Dade County. Specifically, the Court found that the changes made by the
statute at issue in Miami-Dade County “would increase the efficiency and
effectiveness of Medicaid managed care plans statewide by assuring a greater
number of established and financially viable plan providers in the state’s largest
Medicaid market.” Humana, 898 So. 2d at 1045. The Court also favorably
considered the fact that “the Act was enacted as a part of a statewide program”
when it held that the challenged statute was a general law. Id.
Like the statutes that were challenged in St. Johns, Schrader, and Humana,
section 395.4025(16)(c), Florida Statutes, was enacted as part of comprehensive
legislative reform, in the 2018 Trauma Law, of a statewide program, the trauma
system. As discussed, supra, the trauma system is an interconnected network of
health care providers and facilities that provide care to the most critically injured
patients in the State of Florida. Each trauma center serves as an integral
component of the system designed to provide trauma services throughout the state.
See § 395.40(2), Fla. Stat. (The Legislature defines “inclusive trauma system” as
“a system designed to meet the needs of all injured trauma victims who require
care in an acute-care setting and into which every health care provider or facility
with resources to care for the injured trauma victim is incorporated.”).
NCH contends that section 395.4025(16)(c), Florida Statutes, is a special
law that “grants a privilege” to KRMC that other hospitals do not receive. NCH
claims this unique privilege results in an unconstitutional, special law. However,
NCH improperly segregates section 395.4025(16)(c), Florida Statutes, from all
other parts and sub-parts of the sweeping legislation contained in the 2018 Trauma
Law. It has ignored numerous sections which comprise this all-encompassing bill.
The multiple overlooked provisions address a variety of factors and components
which serve to overhaul Florida’s trauma system. Among other measures, the 2018
Trauma Law requires an analysis of the volume of trauma patients treated at
trauma centers and other hospitals; it restructures the trauma center application
review process; it creates an advisory council to offer recommendations from
experts and stakeholders to legislators. More importantly for the purpose of this
appeal, the 2018 Trauma Law also clarifies in section 395.4025(16), Florida
Statutes, the licensure status of all trauma centers operating at the time of the
enactment. Taken as a whole, as is required pursuant to the legal precedent
discussed above, sub-part (16) of section 395.4025, Florida Statutes, applies to all
privately and publicly owned hospitals with an operational trauma program in the
State of Florida. This is one of the reasons why section 395.4025(16)(c), Florida
Statutes, does not violate either Article III, Section 10 or Article III, Section
11(a)(12) of the Florida Constitution. Schrader, 840 So. 2d at 1055; see also
Venice HMA, LLC d/b/a Venice Regional Med. Ctr. v. Sarasota County, 228 So. 3d
76 (Fla. 2017) (“The indigent care provision does not grant a privilege to a private
corporation in violation of article III, section 11(a)(12) of the Florida Constitution
because it applies equally to all hospitals in Sarasota County, whether public or
private.”).
Moreover, the legislative intent of Part II of Chapter 395, Florida Statutes,
which was not modified by the 2018 Trauma Law, requires a coordinated approach
between all providers and emergency personnel involved in the “continuum of care
for the trauma victim from injury to final hospital discharge.” § 395.40(4), Fla.
Stat.; see also § 395.401, Fla. Stat. (setting our requirements for trauma services
system plans), § 395.402, Fla. Stat. (designating trauma service areas); § 395.4045,
Fla. Stat. (setting out the requirements for emergency medical service providers,
trauma transport protocols, transport of trauma alert victims to trauma centers, and
interfacility transfers). The interconnected nature of the operational trauma
programs in the trauma system is similar to the interconnected nature of the water
basins and districts in St. Johns. As noted by the Court in St. Johns, although the
challenged statute in that case only created one water basin, that basin was part of
the greater, statewide water management plan that furthered the state functions of
water resource conservation, control, planning, and development. St. Johns, 421
So. 2d at 1069.
Like the Greater St. John River Basin that is connected to the whole
statewide water management plan, KRMC, and the other trauma programs listed in
section 395.4025(16), Florida Statutes, are interconnected with the emergency
medical service providers, the other trauma programs, the trauma service areas,
and the trauma system, as a whole. Specifically, Level I trauma programs, which is
KRMC’s designation pursuant to the challenged statute, participate “in an inclusive
system of trauma care, including providing leadership, system evaluation, and
quality improvement activities.” § 395.4001(7)(c), Fla. Stat. Level I trauma
programs also serve “as a resource facility to Level II trauma centers, pediatric
trauma centers, and general hospitals through shared outreach, education, and
quality improvement activities.” § 395.4001(7)(b), Fla. Stat.
Additionally, the Legislature explicitly indicated in Section 14 of the 2018
Trauma Law that the licensure status of all the trauma programs in the State of
Florida were meant to be considered together with all the other provisions in the
act:
If the provisions of this act relating to s. 395.4025(16),
Florida Statutes, are held to be invalid or inoperative for
any reason, the remaining provisions of this act shall be
deemed to be void and of no effect, it being the
legislative intent that this act as a whole would not have
been adopted had any provision of the act not been
included.
Although NCH urges the Court to disregard this clear provision, Florida precedent
requires that the Court do otherwise. As discussed, St. Johns, Schrader, and
Humana all hold that statutes enacted as part of a statewide plan must be
considered in context of that larger plan. Furthermore, Florida precedent holds that
“statutes relating to the same subject matter should be read in pari materia, and
such rule is particularly applicable where such statutes are enacted as part of the
single act.” Scherer v. Volusia County Dep’t of Corrections, 171 So. 3d 135, 139
(Fla. 1st DCA 2015) (quoting G.G. v. Fla. Dep’t of Law Enforcement, 97 So. 3d
268, 272 (Fla. 1st DCA 2012)).
Moreover, KRMC provides an integral service for which the Legislature has
previously found increased access to is needed. § 395.40(1), Fla. Stat. (“The
Legislature finds that there has been a lack of timely access to trauma care due to
the state’s fragmented trauma system.”) Accordingly, section 395.4025(16),
Florida Statutes, as a whole, and section 395.4025(16)(c), Florida Statutes, in
particular, as enacted in the 2018 Trauma Law, are reasonably related to the
purpose of the statute, which is to ensure continued and expanded access to trauma
services. Section 395.4025(16)(c), Florida Statutes, ensured that Miami-Dade
County did not lose one of its operational Level I trauma programs as a result of
the new legislation. This, in turn, protected trauma victims’ timely access to a
Level I trauma program in southern Miami-Dade County.
KRMC has been a fully operational Level I trauma program since 2016. As
a result of this designation, KRMC treats some of the most critical and complex
trauma cases in Miami-Dade County. Notably, a “trauma victim” is defined as
“any person who has incurred a single or multisystem injury due to blunt or
penetrating means or burns and who requires immediate medical intervention or
treatment.” § 395.4001(19), Fla. Stat. (emphasis added). The trauma services
provided to trauma victims are of statewide importance, since they ensure the
public health and well-being of these patients. Additionally, as indicated in the
section above, ensuring the public health and well-being of the state’s population is
also related to the state’s function.
iii. The “Open Class” Test Does Not Apply to Section 395.4025(16)(c),
Florida Statutes.
NCH argues that section 395.4025(16)(c), Florida Statutes, should be
stricken as an impermissible special law. NCH’s arguments are based on its
erroneous belief that the holdings in cases like St. Johns, Schrader, and Humana
cannot apply to the case at issue because the challenged statute in this case applies
to a program instead of a location. Due to this, NCH argues that the Court should
apply the “open class” test to section 395.4025(16)(c), Florida Statutes, and find
that the challenged statute is a special law because it only applies to KRMC. The
“open class” test states that “the criterion that determines if a reasonable
relationship exists between the classification adopted and the purpose of the statute
is whether the classification is potentially open to additional parties.” License
Acquisitions, LLC v. Debary Real Estate Holdings, LLC, 155 So. 3d 1137, 1143
(Fla. 2014).
NCH’s application of the “open class” test to the challenged statute misses a
key factor in this case. Section 395.4025(16)(c), Florida Statutes, relates to a state
function or instrumentality, the trauma system. As was discussed in Section I(a)(i)
above, by its very nature, a law relating to a state function or instrumentality
cannot be a special law. St. Johns, 421 So. 2d at 1069 (quoting State ex rel. Gray v.
Stoutamire, 179 So. 730, 733 (Fla. 1938) (“the organic law does not contemplate or
require previous publication of notice of proposed laws for the exercise of State
powers and functions though they may be more or less local or special in their
operation or objects.”) The Legislature’s decision to clarify each operational
trauma center’s licensure status in section 395.4025(16), Florida Statutes, is
squarely a law that deals with the State’s function in ensuring the public health and
safety of its citizens through a statewide comprehensive trauma plan.
Conversely, the statutes at issue in the cases cited by NCH in support of its
arguments did not relate to a state function or instrumentality. In License
Acquisitions, the Florida Supreme Court considered whether a statute that
permitted the holder of a pari-mutuel permit to change the class of the permit from
jai-alai to greyhound if the permit or permit-holder met certain criteria was a
general law. While the Court found that the State had a pecuniary interest in racing
due to the revenue it receives from the tracks, the statute did not serve a state
function. License Acquisition, 155 So. 3d at 1145. The Florida Supreme Court
addressed this in Department of Business Regulation v. Classic Mile, Inc.:
Appellants attempt to salvage section 550.355(2) as a
general law by emphasizing . . . that the regulatory
responsibilities given to the state under the statute are
part of the overall statewide regulatory scheme for the
parimutuel industry, thereby rendering the statute a
general law. . . . As we have already said, the primary
purpose of section 550.355(2) is the establishment of
facilities for the receipt of simulcast horse races. It
cannot be said that this is an important and necessary
state function. Further, if under the statute a facility can
operate only in Marion County, this statute does not have
a broad impact on the state. The mere fact that revenue
might be generated by a statute generally cannot provide
the basis for finding statewide impact; to hold otherwise
would require validation of all revenue-generating
statutes as general laws.
541 So. 2d 1155, 1159 (Fla. 1989). The Court in Classic Mile additionally
distinguished the facts in that case from other cases where the Court found statutes
with limited applications to be general laws due to the fact that the challenged
statutes related to a state function:
Appellants seek to bolster their argument by stressing the
statewide impact of revenue that might be generated by
the statute and cite St. Johns River Water Management
District v. Deseret Ranches, 421 So.2d 1067
(Fla.1982); State v. Florida State Turnpike Authority, 80
So.2d 337 (Fla.1955); Cantwell v. St. Petersburg Port
Authority, 155 Fla. 651, 21 So.2d 139 (1945), as support
for their position. In each of these cases this Court upheld
as general laws statutes which, on their faces, appeared to
affect only limited geographic areas of the state, and
found that the primary purpose of the statutes
contemplated important and necessary state functions and
that the actual impact of the statutes far exceeded the
limited geographic area identified by the terms of the
statutes.
Id. Accordingly, when License Acquisition and Mile are read together it becomes
clear that the reason why the Court applied the “open class” test in both cases is
because the challenged statutes in those cases, while relating to a state interest, did
not relate to a state function. This is clearly different and distinguishable from the
statute at issue in this case that relates to the important and necessary state function
of ensuring the public health and safety of the State’s citizens through a statewide
comprehensive trauma plan.
Additionally, the reason why the “open class” test is used in License
Acquisition is the same reason why the Court applies the “open class” test in R.J.
Reynolds Tobacco Co. v. Hall. 67 So. 3d 1084, 1091 (Fla. 1st DCA 2011) (“the
State's pecuniary interest in the revenue stream under the FSA is a matter of
significant statewide importance and that the bond limitations in section
569.23(3) are reasonably related to this important state interest.”). As the Court
noted, the State’s interest in the revenue from the Florida Settlement Agreement is
an important one, which justifies the narrower focus of the challenged statute in
that case. However, the Court still applies the “open class” test to the challenged
statute because, although it touches on an important state interest, it is not a statute
related to a state function or instrumentality. It is important to note, though, that
R.J. Reynolds shows that the applicability of the “open class” analysis is dependent
on whether the statute relates to a state function, instead of whether the statute
applies to an entity (“special law”) or a location (“local law”). NCH admits this
distinction in its brief, but fails to recognize that the determinative factor in the
case is whether the statute is related to a state function. I.B. 29. Since section
395.4025(16)(c), Florida Statutes, was enacted as part of a statewide plan for the
trauma system and because it serves a state function, the “open class” test is not
applicable in this case.
NCH also cites St. Vincent’s Medical Center, Inc. v. Memorial Healthcare
Group, Inc. in support of its argument that section 395.4025(16)(c), Florida
Statutes, is an impermissible special law. 967 So. 2d 794 (Fla. 2007). The statute at
issue in St. Vincent’s “created an exemption from the [Certificate of Need]
requirement for any adult open-heart surgery program meeting the statute’s
criteria.” Id. at 796. However, as the statute was written, only one program could
meet the requirements for the exemption. The major distinction between the case at
issue and St. Vincent’s is that the open-heart program that was created in St.
Vincent’s was not part of a statewide plan, like the trauma system, that addressed a
specific state function. Instead, the challenged statute in St. Vincent’s took the
program out of the statewide plan, the Certificate of Need program, that was used
at the time to review and approve new healthcare services. In this regard, the
challenged statute in St. Vincent’s has the opposite effect that section
395.4025(16)(c), Florida Statutes, has, which is to keep an operational Level I
trauma program within the trauma system.
Based on the foregoing, the cases cited by NCH do not provide support for
NCH’s arguments. Therefore, since section 395.4025(16)(c), Florida Statutes, is a
statute that relates to a state function and one that has a statewide impact, this
Court should affirm the trial court’s Final Judgment and find that the challenged
statute is a constitutional general law.
b. Section 395.4025(16)(c), Florida Statutes, is a General Law as it is Based on
a Permissible Classification
A statute that operates “uniformly within permissible classifications by
population of counties or otherwise” is a general law. Schrader, 840 So. 2d at
1055 (emphasis added). Furthermore, it is established precedent in Florida that
“[l]aws based upon proper classifications may be general laws even though they
are applicable in only part of the State, or to a part of the people of the State, or to
a part of the property in the State.” State ex rel. Gray v. Stoutamire, 179 So. 730,
734 (Fla. 1938).
In its initial brief, NCH argues that section 395.4025(16)(c), Florida
Statutes, is a special law because KRMC is the only trauma program that falls
within the specified class. However, this argument fails to recognize that the
classification used in section 395.4025(16)(c), Florida Statutes, is not only a
permissible classification, but, in fact, is a necessary one to ensure that the statute
does not interfere with KRMC’s vested rights.
As previously discussed, KRMC originally applied to become a Level I
trauma program in early April 2016. (R. 250.) Subsequently, on April 28, 2016,
DOH designated KRMC as a provisionally approved Level I trauma program,
since KRMC had substantially complied with the Trauma Standards in its
application. (R. 233) Once KRMC was provisionally approved as a Level I trauma
program, it began accepting and treating Level I trauma patients. This not only
required KRMC to undergo significant changes as a result of the designation, but it
also required changes to the emergency transport protocols in Miami-Dade County.
(R. 221-23.) After KRMC was designated as a provisional Level I trauma program,
emergency medical technicians transporting trauma patients were required, in most
circumstances, to bring those patients needing Level I care to KRMC if it was the
closest Level I trauma program. (R. 221-23.)
After KRMC was designated a provisional Level I trauma program, it
continued to work towards meeting the requirements for full Level I trauma
program verification. This was in spite of the fact that NCH initiated an
administrative challenge to the DOH’s decision to provisionally approve KRMC’s
Level I trauma program. At the time that KRMC was advancing though the trauma
program’s Level I verification, the next steps in the process required that it
undergo an in-depth review of its application and a site-survey of its program.
KRMC completed and passed the in-depth review on September 29, 2016 (R. 230.)
KRMC also completed and passed the site-survey on June 4, 2017. (R. 231.)
Accordingly, by July 5, 2017, KRMC had met all of necessary requirements to
become verified as a Level I trauma program. (R. 238.) Although the Department
considered KRMC to have met all of the verification requirements, it could not
designate KRMC as a verified Level I trauma program due to NCH’s pending
administrative challenge to KRMC’s provisional approval. (R. 738.) By the time
the 2018 legislative session began, KRMC had been in this position for nearly six
months. During those six months, however, KRMC continued to treat Level I
trauma patients as required.
As part of this proceeding, NCH argues that section 395.4025(16)(c), Florida
Statutes, is a special law because it only impacts KRMC’s Level I trauma program.
However, what NCH fails to recognize, is that section 395.4025(16)(c), Florida
Statutes, is a permissible classification that works uniformly to ensure that vested
rights that were equitably acquired are not impermissibly abrogated.
At the time that the Florida Legislature was considering how to restructure
the trauma program, KRMC had already completed and passed all of the necessary
steps to attain verification for its Level I trauma program. There was nothing left
for KRMC to do, as part of the application process, to become a verified program.
Accordingly, KRMC had a vested substantive right in its trauma program’s Level I
verification.
A statute is a substantive one when it prescribes duties and rights; this is
different than a procedural statute that creates the means and methods of enforcing
the substantive duties and rights. Kenz v. Miami-Dade County, 116 So. 3d 461, 464
(Fla. 3d DCA 2013). This is a critical distinction because “[s]ubstantive rights
cannot be adversely affected by the enactment of legislation once those rights have
vested.” Bitterman v. Bitterman, 714 So. 2d 356, 363 (Fla. 1998). Additionally, the
Legislature cannot “increase an existing obligation, burden or penalty to a set of
facts after those facts have occurred.” Id.; Blaesser v. State Bd. of Admin., 134 So.
3d 1013, 1015 (Fla. 1st DCA 2012) (“A statute cannot be constitutionally applied
retroactively if it ‘impairs vested rights, creates new obligations, or imposes new
penalties.’”).
Florida cases also hold that a vested right in a license or permit can be
created, in the face of subsequent changes in the law, once a party reasonably and
detrimentally relies on the existing law that would allow the party to hold the
license or permit. Hollywood Beach Hotel Co. v. City of Hollywood, 329 So. 2d 10
(Fla. 1976); Texas Co. v. Town of Miami Springs, 44 So.2d 808, 809 (Fla.
1950) (holding that because oil company spent $12,500 to build gas stations, the
case was “pregnant with equity,” and “a typical case of estoppel”); Bregar v.
Britton, 75 So.2d 753, 756 (Fla. 1954) (plaintiff spent about $28,000 to build a
drive-in movie theater, thus giving rise to equitable estoppel); Town of Largo v.
Imperial Homes Corp., 309 So.2d 571, 572–73 (Fla. 2d DCA 1975) (plaintiff spent
over $379,000 in reliance on existing zoning laws); Equity Resources, Inc. v.
County of Leon, 643 So.2d 1112, 1119 (Fla. 1st DCA 1994) (holding a vested right
to exist when “the county continuously issued permits for the unrestricted
construction of the project over a period of 18 years with knowledge of
expenditures for improvements to be made for the benefit of” the plaintiff's land);
Coral Springs Street Systems, Inc. v. City of Sunrise, 371 F.3d 1320, 1334 (11th
Cir. 2004) (“The Florida courts have made it abundantly clear that when a property
owner incurs a substantial investment of time or money in reasonable reliance on
existing laws and with no reason to know that the laws are likely to change, he may
acquire a vested right in a building permit.”). Accordingly, if a court finds that a
party has reasonably and detrimentally relied on existing law, then a vested right is
created in equity that cannot be adversely affected by a subsequent change in the
law.
Section 395.4025(16), Florida Statutes, identifies all the trauma programs
that were in existence, either through provisional approval or verification, at the
time that the 2018 Trauma Law was enacted. Section 395.4025(16)(c), Florida
Statutes, in particular, identifies the Level I trauma programs that were
provisionally approved in the State of Florida and were already providing services
to their communities. Although KRMC is the only program that Section
395.4025(16)(c), Florida Statutes, applied to, that is only because there were no
other provisionally approved Level I trauma programs in the State of Florida at that
time.2 Accordingly, section 395.4025(16)(c), Florida Statutes, applies uniformly to
the existing provisional Level I trauma programs at the time that the 2018 Trauma
2 Notably, no other trauma program had applied to become a Level I trauma
program for at least two years prior to the enactment of the 2018 Trauma Law. (R.
251.)
Law was enacted. See State ex rel. Gray v. Stoutamire, 179 So. 730, 734 (Fla.
1938).
Section 395.4025(16), Florida Statutes, also ensures that the 2018 Trauma
Law is not impermissibly applied in a manner that impairs the vested rights of the
operational trauma programs. If section 395.4025(16), Florida Statutes, had not
been included in the 2018 Trauma Law there would be significant confusion as to
how the new law would apply to trauma programs that had already attained a
vested interest in their verification. KRMC could have reasonably argued that it
had a vested right in its verification, even though its program was designated as a
“provisional” Level I trauma program, since it had completed all of the necessary
requirements to become a verified Level I trauma program.
Accordingly, when enacting the 2018 Trauma Law the Legislature did not
create a new right for KRMC in section 395.4025(16)(c), Florida Statutes. Instead,
the Legislature used a grandfather clause, which is a permissible tool in statutory
construction, to protect KRMC’s vested right in its Level I trauma program
verification. This is legally acceptable as the Florida Supreme Court has previously
held that grandfather clauses are favored in the law “because they tend to protect
rights either existing or in the process of being obtained prior to cut-off dates.”
Hartman Transp., Inc. v. Bevis, 293 So. 2d 37 (Fla. 1974).
NCH is likely to argue that the Legislature could not enact legislation that
protects KRMC’s vested right to its Level I trauma program verification without
taking into consideration NCH’s administrative challenge to KRMC’s provisional
approval. However, this Court has previously addressed this issue in Lakeland
Regional Medical Center, Inc. v. Agency for Health Care Administration, 917 So.
2d 1024, 1033 (Fla. 1st DCA 2006). In Lakeland Regional, the Court considered
whether the Legislature could enact a grandfather clause3 that granted a certificate
of need (“CON”) for an open heart surgery program to hospitals, including Winter
Haven Hospital, that had already received a notice of intent to grant a certificate of
need by the Agency for Health Care Administration, but could not be issued the
CON since the Agency’s decision was administratively challenged by a competing
hospital. When analyzing whether the Legislature’s decision to enact the
grandfather clause approving the CON, despite Lakeland Regional’s administrative
challenge, was constitutional, the Court held the following:
3 The grandfathering language at issue in Lakeland Regional states:
Existing providers, any provider with an exemption for
open heart surgery, and any provider with a notice of
intent to grant a certificate of need or a final order of the
agency granting a certificate of need for adult
interventional cardiology services or burn units shall be
considered grandfathered-in and shall receive a license
for their programs effective on July 1, 2004, or the date
their program becomes operational, whichever is later.
Id. at 1028-29 (quoting Ch. 2004-383 at 2934, Laws of Fla.).
Lakeland Regional's administrative challenge to Winter
Haven Hospital's application had not become final at the
time the grandfather clause became effective.
Accordingly, Lakeland Regional had only a mere
expectation of a continuing right under the
statute. See Lamb v. Volkswagenwerk Aktiengesellschaft,
631 F.Supp. 1144, 1149 (S.D.Fla.1986) (ruling that the
plaintiff, with a pending lawsuit on a tort claim, had no
vested property right because she only had a “prospect” to
recover damages, and the statute of repose revived by
a court ruling eliminated the cause of action); Clausell v.
Hobart Corp., 515 So.2d 1275, 1276 (Fla.1987) (holding
that application of statute to bar pending cause of action
did not violate due process, citing and quoting extensively
from Lamb). Therefore, Lakeland Regional has no vested
constitutionally protected property right and the 2004
statutory changes do not violate due process.
Id. at 1032-33. Additionally, the Court also noted the following:
The grandfather amendment is rationally related to the
legitimate government interest of transitioning from a
CON regulatory scheme to a licensure scheme. It was not
irrational for the legislature to include within the
grandfather amendment hospitals who had been granted
notices of intent to issue a CON by AHCA. A notice of
intent is only awarded after AHCA reviews the CON
application and a CON would have been awarded to
Winter Haven Hospital based on this review had
Lakeland Regional not challenged the application.
Id. at 1033. Therefore, Lakeland Regional establishes: a) that an administrative
challenge to an agency’s decision to license or permit a health program does not
create a protected property right for the challenging party, and b) that the
Legislature can use a grandfather clause to fully license or permit a health program
that was preliminarily or provisionally approved by an agency, even when an
administrative challenge by a competing hospital is pending. This is true even
though the grandfather clause in Lakeland Regional created a “closed class” as no
other hospitals that were not currently in existence at the time that the law was
enacted could be grandfathered in. Therefore, this supports the conclusion that a
grandfathering clause can be a general law, like here, when it uses a permissible
classification that applies uniformly.
Like Winter Haven Hospital in Lakeland Regional, KRMC’s Level I trauma
program would have been verified, prior to the enactment of section
395.4025(16)(c), Florida Statutes, based on the DOH’s in-depth review of the
application and the site survey of the program if NCH had not challenged the
program’s provisional approval. Accordingly, the Legislature used a proper
classification, through a grandfathering clause, that was uniformly applied, to
designate KRMC as a verified Level I trauma program, since KRMC had already
met all the necessary requirements for verification. Due to this, this Court should
hold that section 395.4025(16)(c), Florida Statutes, is a general law that does not
violate either Article III, Section 10 or Article III, Section 11(a)(12) of the Florida
Constitution. The trial court’s Final Judgment in this case should be affirmed.
CONCLUSION
NCH’s appeal lacks merit as section 395.4025(16)(c), Florida Statutes, is a
general law that does not violate either Article III, Section 10 or Article III, Section
11(a)(12) of the Florida Constitution. Therefore, the Appellee, Jackson South,
respectfully requests that this Court issue an opinion holding that section
395.4025(16)(c), Florida Statutes, as enacted in Chapter 2018-66, Laws of Fla., is a
constitutionally valid general law. Furthermore, the Court should affirm the Final
Judgment issued by the trial court in this matter on May 16, 2019.
Respectfully submitted,
CHRISTOPHER C. KOKORUDA
Assistant Miami-Dade County Attorney
1611 N. W. 12th Avenue
West Wing, Suite 109
Miami, Florida 33136
Florida Bar No. 86501
EUGENE SHY, JR.
Assistant Miami-Dade County Attorney
Florida Bar No. 278653
SUZANNE VILLANO
Assistant Miami-Dade County Attorney
Florida Bar No. 19154
Telephone: (305) 585-1313
Facsimile: (305) 326-8239
Primary: [email protected]
Secondary: [email protected]
and
THOMAS F. PANZA, ESQUIRE
PANZA, MAURER & MAYNARD, P.A.
Coastal Towers
2400 E. Commercial Boulevard, Suite 905
Fort Lauderdale, FL 33308
Phone:(954) 390-0100
Fax: (954) 390-7991
By: /s/ Thomas. F. Panza
Fla. Bar No. 138551
PAUL C. BUCKLEY, ESQUIRE
Fla. Bar No.906697
ANGELINA M. GONZALEZ, ESQUIRE
Fla. Bar No. 98063
Counsel for The Public Health Trust of
Miami-Dade County, Florida
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a true and correct copy of the foregoing was filed
and served via electronic filing this 4th day of November, 2019 with:
Seann M. Frazier, Esq.
Marc Ito, Esq.
Kristen Bond
Parker, Hudson, Rainer, & Dobs LLP
215 S. Monroe St., Suite 750
Tallahassee, FL 32301
Counsel for Nicklaus Children’s
Hospital
Amber Stoner Nunnally, Esq.
Jason Gonzalez, Esq.
Shutts and Bowen, LLP
215 S. Monroe Street, Suite 804
Tallahassee, FL 32302
Counsel for the Florida
Department of Health
Stephen A. Ecenia, Esq.
J. Stephen Menton, Esq.
Gabriel F. V. Warren, Esq.
Rutledge Ecenia
119 S. Monroe Street, Suite 202
Post Office Box 551
Tallahassee, FL 32302-0551
Raoul G. Cantero, Esq.
David P. Draigh, Esq.
White & Case, LLP
Southeast Financial Center
200 S. Biscayne Blvd., Ste. 4900
Miami, FL 33131-2352
Counsel for Kendall Regional
Medical Center
Co-Counsel for Kendall Regional
Medical Center
Michael Williams, Esq.
Department of Health
4052 Bald Cypress Way
Tallahassee, FL 32399
Counsel for the Florida
Department of Health
/s/ Thomas F. Panza
THOMAS F. PANZA
CERTIFICATE OF COMPLIANCE
I HEREBY CERTIFY that the Appellee’s, The Public Health Trust of
Miami-Dade County, Florida, d/b/a Jackson South Medical Center, Answer Brief
complies with the font requirements of Florida Rule of Appellate Procedure
9.210(a)(2) and is submitted in Times New Roman 14-point font.
/s/ Thomas F. Panza
THOMAS F. PANZA
