Update on Private Enforcement of Medicaid Act

Update on Private Enforcement of the Medicaid Act Pursuant to 42 U.S.C. § 1983 
Medicaid recipients and applicants may be harmed when state Medicaid officials do not comply with the requirements of the Medicaid Act, 42 U.S.C. §§ 1396-1396v. These individuals may file suit in court to obtain injunctive relief. Traditionally, Medicaid recipients have enforced the provisions of the Medicaid Act pursuant to a civil rights statute, 42 U.S.C. § 1983 (?§ 1983?).2  More recently and as discussed below, the ability to use § 1983 to enforce Medicaid provisions has been narrowed, and plaintiffs have turned to long-standing constitutional precedents allowing them to rely on the Supremacy Clause of the Constitution to obtain relief under a preemption claim.3  Currently, the U.S. Supreme Court is considering whether individuals and providers may maintain a cause of action under the Supremacy Clause to enforce a provision of the Medicaid Act, § 1396a(a)(30)(A), which requires states to establish adequate payment rates for participating providers.4
While attention has been focusing on the preemption arguments, carefully constructed cases remain viable under § 1983. This Fact Sheet will provide brief background and discuss trends affecting private enforcement of the Medicaid Act under § 1983.5

Background 

At the time of our Nation?s founding, the constitutional framers worked against the backdrop of English laws and principles. Among these was the ?invariable principle . . . that every right, when withheld, must have a remedy, and every injury its proper redress.?6  The Supreme Court?s landmark decision, Marbury v. Madison, reflects this notion, stating that ?the very essence of civil liberty? is the ?right of every individual to claim the protection of the law, whenever he receives an injury. One of the first duties of government is to afford that protection.?7
Over the years, private individuals have gone to court to obtain prospective injunctive relief when they are being harmed by state actions that are inconsistent with federal law. Some of these federal laws were enacted by Congress pursuant to the Spending Clause of the Constitution, and they make federal funding available to states that agree to operate the funded programs consistent with the requirements of the federal law.8  The Social Security Act, of which Medicaid is a part, is an example of a Spending Clause enactment. When it added Medicaid to the Social Security Act in 1965, Congress did not include a provision authorizing individuals to enforce the Act in federal court. But in enacting Medicaid, as with other public benefits programs, Congress acted with the understanding that courts would ?provide such remedies as are necessary to make effective the congressional purpose.?9 For example, in King v. Smith, the Court allowed welfare recipients to enforce the ?reasonable promptness? provision of the Social Security Act?s welfare law pursuant to § 1983. 10 In Maine v. Thiboutot, a 6-3 ruling, the Court again addressed enforcement under § 1983 and held that ?the phrase ?and laws? means what it says? and, thus, § 1983 enforcement applies not only to constitutional rights but also to rights defined in federal statutes.11
Subsequently, however, the Court cautioned that § 1983 actions require the plaintiff to assert a violation of a federal ?right,? not merely a violation of federal law.12 The Supreme Court has announced a three-prong test for lower courts to use to determine whether a federal law creates a federal right: (1) Was the federal provision in question intended to benefit the plaintiff; (2) Does the provision contain sufficiently specific language so that a court knows what to enforce; and (3) Does the provision create a binding obligation on the state?13 If these questions are answered affirmatively, there is a presumption that the plaintiff can enforce the provision. The defendant can overcome the presumption by showing that Congress has foreclosed enforcement through § 1983, expressly or by including a comprehensive remedial scheme in the substantive federal law.14  The Supreme Court has explicitly held that the Medicaid Act does not include such a remedial scheme.15

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