Medina v. Planned Parenthood South Atlantic

Issues

Does the Medicaid Act’s any-qualified-provider provision give Medicaid beneficiaries a private right to choose their provider?

Oral argument:
April 02, 2025
Court below:
United States Court of Appeals for the Fourth Circuit

This case asks the Court to determine when an individual, private right is enforceable under 42 U.S.C. § 1983. South Carolina’s executive order deems abortion clinics enrolled in the Medicaid program as unqualified to provide family planning services. Planned Parenthood South Atlantic and its patient, Julie Edwards, contend that the executive order violates Ms. Edwards’s right to choose a qualified provider under 42 U.S.C. § 1396a(a)(23), the any-qualified-provider provision. South Carolina counters that the any-qualified-provider fails to create a private right of action enforceable through § 1983 because Congress did not use unambiguously clear rights-creating language. The outcome of this case has heavy implications for Medicaid beneficiaries and providers, the implementation of state and federal healthcare policy goals, and the litigation of private rights.

Questions as Framed for the Court by the Parties

Whether the Medicaid Act’s any-qualified-provider provision unambiguously confers a private right upon a Medicaid beneficiary to choose a specific provider.

Facts

The Medicaid Act provides medical assistance to certain individuals and families who cannot cover the cost of necessary medical services due to insufficient income and resources. Enacted through Congress’s spending power , Congress disburses federal funds to states to accomplish this goal. To receive the funds, states must comply with congressionally imposed conditions by submitting plans for medical assistance to the Secretary of Health and Human Services (“HHS”). Funding may be withheld if the Secretary is not satisfied by a state’s compliance. One of the requirements imposed by the Medicaid Act is the any-qualified-provider provision, 42 U.S.C. 1396a(a)(23)(A) . This provision provides that, “any individual eligible for medical assistance… may obtain such assistance from any [provider] qualified to perform the service or services required… who undertakes to provide him such services[.]”

In July 2018, the Governor of South Carolina issued an executive order directed to South Carolina’s Department of Health and Human Services (“DHHS”). The order directed DHHS “to deem abortion clinics… that are enrolled in the Medicaid program as unqualified to provide family planning services and, therefore, to immediately terminate them upon due notice.” DHHS informed Planned Parenthood , a sexual and reproductive health-care provider, that it was “no longer… qualified to provide services to Medicaid beneficiaries” and that its “enrollment agreements with the South Carolina Medicaid programs [were] terminated[.]”

Prior to the executive order, Planned Parenthood South Atlantic , offered a wide range of services, including but not limited to abortion, to both Medicaid and non-Medicaid patients in South Carolina. Following the executive order, Respondents Planned Parenthood South Atlantic and Edwards, a South Carolinian insured through Medicaid who sought medical care at Planned Parenthood clinics, (collectively “Planned Parenthood”) sued then South Carolina’s Director of DHHS Robert Medina under 42 U.S.C. § 1983 . Section 1983 allows for a private, federal remedy against any person who, acting under color of state law , has deprived a party of "any rights, privileges, or immunities secured by the Constitution and laws" of the United States.

Planned Parenthood sought to enjoin enforcement of the executive order as applied to Planned Parenthood and alleged that Medina violated the any-qualified-provider provision. The district court granted summary judgment in favor of Planned Parenthood and issued a permanent injunction prohibiting the termination of Planned Parenthood’s Medicaid provider agreements. Medina appealed and the United States Court of Appeals for the Fourth Circuit held that the any-qualified-provider provision created an individual, federal right which could be brought via a § 1983 claim and that the executive order violated this right.

Medina petitioned the Supreme Court of the United States for a writ of certiorari . While that petition was pending, the Court decided Health & Hospital Corp. of Marion County v. Talevski . The Court granted Medina's petition, vacated the Fourth Circuit’s judgment, and remanded the case to the Fourth Circuit for further consideration in light of Talevski . The Fourth Circuit described the key holding in Talevski as tasking the court with determining whether Congress has unambiguously conferred individual rights upon a class of beneficiaries. The Fourth Circuit again held that the any-qualified-provider provision provides an individual right enforceable via § 1983.

Accordingly, Medina petitioned the Court again on June 03, 2024, to hear this case. The Court granted certiorari on December 18, 2024.

Analysis

TEXTUAL CONFERENCE OF A RIGHT

Eunice Medina, Interim Director, South Carolina Department of Health and Human Services (“Medina”), argues that in order to create an enforceable right under § 1983 in a spending clause statute, the statute must show Congress’s unambiguous intent to confer a right, which the any-qualified-provider provision fails to do. According to Medina, the provision lacks explicit rights-creating language. Medina argues that the absence of any text that specifies a “right” or states that “no person shall” infringe on that right indicates a lack of intent to confer a right. Medina elaborates that Congress intentionally included the term “right” in other sections of § 1396, and therefore any intention to include a right in the any-qualified-provider provision can only be inferred. According to Medina, the ambiguity of an inference precludes any possible intent to create an enforceable right.

Additionally, Medina argues that the any-qualified-provider provision fails to direct its language toward a benefitted class, another requirement imposed on spending clause statutes. Instead, Medina believes that the language of the provision speaks only to the Secretary of Health and Human Services, removing its directive from the individuals receiving the benefit. Medina asserts that when Congress phrases a statute as a directive toward a federal agency, it cannot confer an individual right. For instance, Medina compares the provision to the Davis-Bacon Act , which the Court recognized as for the benefit of construction workers but still determined that its language commanded a federal agency to include certain stipulations for the workers and therefore provided no private remedy. Here, Medina indicates that the text of the statute directs the Secretary to approve plans that satisfy certain conditions, including the condition in the any-qualified-provider provision. Medina adds that although those plans may confer a benefit, and the language may include the term “individuals,” their direction at the Secretary precludes the conference of a right onto any individual.

Planned Parenthood South Atlantic (PPSAT), counters that there are no “magic words” required for Congress to show its intent to confer a right. PPSAT furthers that in two out of the three other statutes found to have conferred rights, Congress did not include the word “right.” Instead, PPSAT emphasizes that the language “must” provide that “any individual eligible for medical assistance” under Medicaid “may obtain” care from his or her chosen provider explicitly references rights. PPSAT
contends that “must” refers to a mandatory obligation or a right, and that “may obtain” refers to choice which signifies a right. PPSAT explains that not only is there no specific language required to confer a right, but further that federal courts cannot impose any specific language because separation of powers designates writing statutes to Congress.

PPSAT contends that the focus of the any-qualified-provider provision lands on the beneficiaries or the rights bearers. PPSAT specifies that the language of the statute does not mention the Secretary and instead refers to state plans that confer rights to the individual beneficiaries. PPSAT additionally points out that the language of the statute directed at entities other than individuals speaks to the state administering the Medicaid program, which indicates direction to respect and honor the individuals’ statutory rights. PPSAT distinguishes the language of the any-qualified-provider provision from other statutes, such as FERPA in Gonzaga , by explaining that FERPA spoke in the aggregate, referring to institutional policy and practice, whereas the any-qualified-provider provision refers to individuals’ ability to obtain medical care, thus directing its language at the rights bearers.

CONGRESSIONAL INTENT

Medina argues that elements of the any-qualified-provider provision indicate congressional intent not to confer any right. Medina refers to both Health & Hospital Corp. of Marion County v. Talevski and Gonzaga University v. Doe as proof of Congress’s knowledge of how to implement rights creating language to contrast with the text of the any-qualified-provider provision which signifies its intent not to create a right. Medina also points out that other rights-conferring statutes typically reside in sections of those statutes focused on individual rights, whereas here, placing the any-qualified-provider provision in the “contents” section of the “State plans for medical assistance” shows a lack of intent to create a right. Medina also argues that giving the States the ability to limit the scope of the right contradicts typical statutes granting rights and shows an additional lack of intent from Congress.

PPSAT counters that Congressional intent to create a right is evident in the context and history of the any-qualified-provider provision. PPSAT details prior versions of the Medicaid Act which lacked the any-qualified-provider provision and was subsequently amended in order to prevent unfair exclusions and restrictions of qualified providers from participating in Medicaid. PPSAT also references Congressional records and hearings at which legislators referred to the choice of provider as a “right” and indicated the importance of “free choice” of providers. PPSAT indicates that Congress additionally intended to confer a right by choosing to model the Medicaid provision on a similar Medicare provision, which PPSAT argues clearly confers a right. PPSAT also points to a statute referred to as the “ Suter Fix ” which purposely reversed a ruling that rights of action could not be enforceable in state plan requirements, and argues that by implementing this amendment, Congress intended the availability of rights of action under laws such as the Medicaid Act.

ALTERNATIVE RIGHTS OF ACTION

Medina argues that a private right of action under § 1983 is unnecessary because there are already alternative remedies for exclusion. Medina claims that allowing providers to file an administrative appeal for exclusion, followed by allowing review in state and federal courts, is an adequate remedy that is already available. Medina therefore states that creating an additional right for beneficiaries to sue in federal court would serve as a “curious system of review” for the state’s determinations on providers. Medina furthers that creating an express administrative remedy for beneficiaries to challenge both their own eligibility and a provider’s eligibility makes little sense. Considering reasons for needing additional administrative remedies for beneficiaries, Medina also points out that South Carolinians already have access to plenty of healthcare providers, so additional administrative remedies would do little to promote access to healthcare.

PPSAT counters that there is no alternative enforcement scheme, and that Medina fails to make any showing that there is. PPSAT contends that any alternative methods available, such as those promoted by Medina, do not serve any function for beneficiaries to vindicate their choice-of-provider rights. PPSAT first considers that the Secretary of Health and Human Services withholding funds from noncompliant states solely serves as a remedy for the federal government, not for any individual. PPSAT adds that this remedy may even harm the individual, as fully removing funding from a state is a drastic step not benefitting individual participants. Next, PPSAT indicates that the individual’s ability to bring an administrative hearing for a claim denial does nothing to advocate for free choice of provider and only benefits the individual after care has been administered. . PPSAT lastly looks to the providers’ rights to bring an administrative hearing based on their own denial and argues that this also confers no benefit to the individual, as it is a remedy given to the providers who may choose not to exercise it.

Discussion

HEALTHCARE POLICY GOALS

The American Association of Pro-Life Obstetricians and Gynecologists et al., in support of Medina, assert that states should be allowed to prioritize their interest in protecting prenatal life. Liberty Counsel argues that Planned Parenthood focuses on abortion and provides a dwindling spectrum of other healthcare services. According to Heartbeat International , the executive order expresses South Carolina’s culture and intention that State funds not be used to pay for abortions, aligning with the preferences of South Carolina’s taxpayers.

Further, Heartbeat International contends that access to family planning services remains possible without relying on entities like Planned Parenthood because of governmental and nongovernmental entities offering women’s health and family planning services. Heartbeat International points out that, at the time of the executive order, the majority of State expenditures related to Medicaid funding for family planning services already went to entities other than Planned Parenthood. South Carolina Medicaid Practitioners add that maintaining Planned Parenthood as a Medicaid provider would not help the provider shortage in South Carolina’s rural areas since their centers are located in the two largest cities in the State.

Planned Parenthood counters that the any-qualified-provider provision protects a personal right to choose his or her own doctor, a right which is fundamental to a patient’s autonomy and dignity. Planned Parenthood contends Congress designed this right to ensure that the people who need care actually receive it. Additionally, Planned Parenthood argues the freedom to choose a healthcare provider has many benefits, such as improving the quality of medical care by encouraging competition among providers and promoting better health outcomes by improving the trust and personal relationship between the doctor and patient. Centrally, Planned Parenthood argues, this case is about preserving an affordable choice and quality care for Medicaid patients in South Carolina.

Planned Parenthood asserts that South Carolina terminated its participation as a qualified provider in Medicaid because it provides abortion, unfunded by Medicaid. Planned Parenthood maintains that the money Planned Parenthood receives from Medicaid does not fund the abortions it offers to its patients. Planned Parenthood contends that if the State’s rationale is accepted, a state could exclude any provider that it disfavors for any reason.

INCREASED LITIGATION

United States Senators and Representatives argue in support of Medina that allowing private enforcement of the any-qualified-provider provision will impose substantial costs by increasing litigation. World Faith Foundation and NC Values Institute assert that the increase could be drastic, affecting the hundreds of routine Medicaid termination decisions a state makes every year or even including challenges to the State’s failure to list particular providers. Family Policy Alliance and State Family Policy Councils (“Family Policy Councils”) caution that this will divert necessary funding away from healthcare and negatively impact Medicaid beneficiaries. Expanding enforcement mechanisms would, according to Family Policy Councils, create administrative difficulty, strain the resources of the states, and increase an already complex program.

Planned Parenthood counters that only a few provisions of the Medicaid Act employ rights-creating language. As a result, Planned Parenthood contends that if the Supreme Court holds that the any-qualified-provider provision is privately enforceable, it would not result in an explosion of litigation. Planned Parenthood points out that the Sixth Circuit issued its holding 20 years ago that the any-qualified-provider-provision is privately enforceable and has not resulted in an explosion of litigation, even as other Circuits came to the same holding. Further, Planned Parenthood argues that lawsuits are unlikely to increase due to the demographic suing: the potential plaintiffs in these actions are Medicaid patients who often lack the resources to litigate these claims. As such, Planned Parenthood continues, these patients will only litigate the most egregious violations.

Conclusion

: Sara Fischer and Sierra Berry

: Eric Yang

Additional Resources