I. Key Takeaways:
- The Supreme Court of the United States has issued a significant healthcare decision in Medina v. Planned Parenthood South Atlantic, a case which will likely have far-reaching implications for Medicaid beneficiaries and providers nationwide.
- The Medina v. Planned Parenthood case arose from South Carolina's efforts to defund Planned Parenthood. At issue in this case was whether Medicaid beneficiaries have an individual right to challenge state Medicaid actions in federal court for failing to comply with the Medicaid "free choice of provider" provision – a requirement that beneficiaries may choose any willing and qualified provider.
- In a 6-3 decision written by Judge Gorsuch, the Court held that there is no private right of action under 42 U.S.C. § 1983, which was enacted in the Civil Rights Act of 1871, for beneficiaries to enforce the Medicaid "free choice of provider" requirement.
- The Court's ruling severely undermines the "free choice of provider" provision, especially in circumstances where the federal government does not step in to enforce this requirement, which could affect providers far beyond family planning providers.
- With respect to family planning providers, the ruling will have implications beyond South Carolina, as it will likely prompt other states to pursue similar efforts to defund Planned Parenthood and restrict access to family planning and preventive health services.
- The decision also weakens the legal protections that allow Medicaid beneficiaries and providers to challenge other violations of federal Medicaid law.
II. Background
As we wrote about in our Medicaid & the Law blog here, after South Carolina attempted to exclude Planned Parenthood clinics from the state's Medicaid program, the Court in Medina v. Planned Parenthood South Atlantic considered whether Medicaid's free choice of provider provision (also known as the "any-qualified provider" provision) at section 1902(a)(23) of the Social Security Act confers a private right upon a Medicaid beneficiary to choose a specific provider, thereby enabling a Medicaid beneficiary who has been deprived of that right by a state Medicaid plan to challenge that denial in federal court. In a 6-3 decision written by Judge Gorsuch, the Court held that there is no private right of action under 42 U.S.C. § 1983 for beneficiaries to enforce the Medicaid "free choice of provider" requirement. The opinion is available here.
When assessing whether 42 U.S.C. § 1983, which was first enacted as part of the Civil Rights Act of 1871, can be used to enforce Medicaid's free choice of provider requirement, the Court emphasized that with Spending Clause programs like Medicaid, federal statutes do not confer rights enforceable under § 1983 "as a matter of course." Relying on precedent established in Gonzaga University v. Doe. 536 U.S. 273 (2003) and Health and Hospital Corp of Marion County v. Talevski, 599 U.S. 166 (2023), the Court explained that "[s]ection 1983 permits private plaintiffs to sue for violations of federal spending-power statutes only in 'atypical' situations, Talevski, 599 U. S., at 183, the statute must "clearly" and "unambiguously" put states on notice of private enforcement. Gonzaga, 536 U. S., at 290.
The Court then turned to the language of section 1902(a)(23) of the Social Security Act, which requires that state Medicaid plans must "provide that . . . any individual eligible for medical assistance (including drugs) may obtain such assistance from any institution, agency, community pharmacy, or person, qualified to perform the service or services required . . . who undertakes to provide him such services." The Court concluded that this language addresses "what a State must do to participate in Medicaid, and a State that fails to fulfill its duty might lose federal funding." While acknowledging that the statutory provision does confer benefits on both providers and patients, the Court held that the provision does not clearly and unambiguously contain the necessary "rights-creating language" required by Talevski and Gonzaga.
Justice Thomas filed a concurring opinion. Justice Jackson filed a strongly worded dissent, joined by Justices Kagan and Sotomayor.
III. Importance of the Decision
The Court's ruling in Medina v. Planned Parenthood South Atlantic will have implications far beyond family planning providers and outside of South Carolina.
The Court's ruling severely undermines the "free choice of provider" provision, particularly in circumstances where the federal government does not step in to enforce this requirement. States seeking to exclude any kind of providers would be shielded from federal enforcement unless CMS uses its limited resources to make enforcement a priority. Federal agency non-enforcement is generally nonjusticiable. Providers excluded from a state Medicaid program do have state administrative appeal rights, with state court judicial review, possibly followed by Supreme Court review, but those appeal rights are generally limited to reviewing compliance with state requirements. This new enforcement landscape could affect providers far beyond family planning providers.
Under this new backdrop, other states are likely to pursue similar efforts to defund Planned Parenthood and restrict access to family planning and preventive health services. We also may see states exclude providers from Medicaid as a means of restricting access to other politically disfavored care, such as gender affirming care, or pursuing other policy goals.
More broadly, the Court's decision in Medina also weakens the legal protections that allow Medicaid beneficiaries and providers to challenge other violations of federal Medicaid law.
We are continuing to analyze the Supreme Court's decision in Medina v. Planned Parenthood South Atlantic and will provide a more comprehensive analysis of the decision and its implications in a forthcoming post through our Medicaid & the Law blog. If you have any questions about this case or its potential impact on your organization, please contact a member of our Healthcare Department.
Stay informed of recent policy changes. Explore Foley Hoag's Federal Actions Tracker for up-to-date information.
The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.
