Even if you aren’t on Medicaid, chances are you know someone who is. The program is so widespread that it’s effectively a household name. It’s not just low-income Americans who benefit from Medicaid, but also certain people with disabilities and certain groups of children, pregnant women, and seniors. As of January 2025, there were 78.4 million people covered by the program—nearly a quarter of all Americans.
With such a large portion of the population relying on Medicaid, questions about how the program operates and who has the power to enforce its rules are more relevant than ever.
The Supreme Court recently weighed in on one of these questions with a ruling that has sparked debate about the role of the federal government in enforcing Medicaid rules and the ability of individuals to hold their states accountable.
Medicaid’s 'Any Qualified Provider' Provision
Congress created Medicaid in 1965 to help states provide healthcare to people and families who don’t have enough money to pay for necessary medical services. Now, all 50 states take part in Medicaid.
To join, a state has to submit a “plan for medical assistance” to the Secretary of Health and Human Services (HHS). The plan must meet more than 80 different requirements set out by Congress. The Supreme Court's recent decision is about one of those requirements, known as the “any-qualified-provider” rule, which is codified in the federal Medicaid Act at 42 U.S.C. §1396a(a)(23)(A).
The any-qualified-provider rule says that state Medicaid plans must allow:
- Any individual eligible for Medicaid to obtain medical assistance
- From any provider (this could be a doctor, hospital, pharmacy, or agency, for example) who is qualified to perform the service and willing to give it
The rule does not define what “qualified” means, leaving that determination to the states. As SCOTUS has suggested, this omission is not an oversight but rather likely an intentional move by Congress. States have always been primarily responsible for health and safety regulations, including deciding who can practice medicine.
The purpose of the any-qualified-provider rule is to ensure that Medicaid beneficiaries have the freedom to choose among a range of qualified healthcare providers without interference from the government. States participating in Medicaid must include this provision in their plans as a condition for receiving federal funds.
However, states may exclude providers for certain reasons. For example, a provider can be excluded for having a felony conviction, and states have discretion to determine which convictions qualify for exclusion.
A 'Bargain' for States
Once a state’s Medicaid plan is approved by the Secretary of HHS, the federal government begins providing funds to that state to help cover the costs of providing medical assistance to eligible individuals. However, Medicaid is designed as a partnership between the federal government and the states, so both must contribute financially.
The federal government’s share of Medicaid funding is determined by a formula. On average, it covers about 57% of the program's total costs, with the state contributing the other 43%.
The exact percentage the federal government pays can vary from state to state, depending on factors like the state’s per capita income. This arrangement ensures that states have a significant stake in the program and must allocate their own resources to maintain Medicaid services for their residents.
Sounds like a pretty good deal for states, right? The Supreme Court has called it a “bargain.” But the federal government isn’t just giving away free dollars willy-nilly. There’s something in it for them, too.
Congress had several goals in mind when it passed the Medicaid plan. Namely, it wanted to:
- Ensure consistent access to medical care for low-income populations across all states
- Stimulate economic activity through healthcare spending that supports job growth
- Reduce the burden of uncompensated care on hospitals and emergency services
In other words, there are strings attached—purse strings, to be specific.
Power of the Purse
Remember, the federal government doesn't have unlimited power to dictate to states. But it does have a whole lot of money to throw around.
Article I, Section 8 of the Constitution allows Congress to "provide for the general Welfare." It can offer funds to states on the condition that the states comply with certain requirements. This is known as "conditional spending."
States are by no means forced to accept the federal funds. But if they do, they have to play by Congress's rules. This plays out in countless areas outside of healthcare, including education, Social Security, highway funding, clean air and water, and more.
So with Medicaid, too, the feds giveth and the feds taketh away. If a state “fails to comply substantially” with any of the federal requirements, the Medicaid Act gives the Secretary of HHS the authority to respond by withholding some or all of the federal funding that the state would otherwise receive.
This is a significant enforcement tool: the threat of losing federal money is intended to ensure that states follow the rules and maintain the standards set by Congress. The Secretary can continue to withhold funds until the state corrects the problem and comes back into compliance with federal requirements.
In countless cases where conditional spending was involved, the U.S. Supreme Court has emphasized federal oversight. The threat of funding termination is the “typical remedy” for state noncompliance with spending-power statutes.
The Court has stated that, historically and by design, Congress intended for the federal government (instead of private individuals) to enforce the conditions attached to federal funds.
But what happens when the federal government doesn’t step in? Is there anything that the Medicaid beneficiaries themselves can do to make sure their state government is complying with Medicaid requirements? Can they sue?
These are all the questions at the center of the South Carolina case before SCOTUS called Medina v. Planned Parenthood.
Planned Parenthood Sues South Carolina
Planned Parenthood South Atlantic operates two clinics in South Carolina. It offers a wide range of services to both Medicaid and non-Medicaid patients, including performing abortions.
In July 2018, South Carolina determined that Planned Parenthood could no longer participate in the state’s Medicaid program, citing a state law that prohibits the use of public funds for abortion. At the same time, the state took steps it claimed would ensure that other providers would continue to offer necessary medical care and family planning services to Medicaid patients.
In response to this exclusion, Planned Parenthood and one of its patients, Julie Edwards, filed a class action lawsuit against the director of the State’s Department of Health and Human Services, Eunice Medina.
Edwards, a Medicaid beneficiary, alleged that she preferred to receive gynecological care from Planned Parenthood but needed Medicaid coverage to do so. They claimed that the exclusion of Planned Parenthood from the Medicaid program violated the federal Medicaid Act’s “any-qualified-provider” provision, which they argued gave Medicaid recipients the right to obtain services from any qualified provider willing to participate.
Importantly, the plaintiffs brought their action under not the Medicaid Act, but a different statute: 42 U.S.C. §1983. Originally enacted as part of the Civil Rights Act of 1871, this law allows private individuals to file lawsuits in federal court against state or local officials who deprive them of “any rights, privileges, or immunities secured by the Constitution and laws” of the United States.
In this case, the plaintiffs claim that South Carolina’s exclusion of Planned Parenthood from the state’s Medicaid program violates rights they assert are secured by the federal Medicaid statutes.
The plaintiffs asked federal courts to recognize and enforce what they saw as a federal right for Medicaid beneficiaries to choose their healthcare provider and to prevent the state from interfering with that choice. They also asked for an injunction to stop South Carolina from excluding Planned Parenthood from the Medicaid program, arguing that such an exclusion violated federal law and the rights of Medicaid patients under that law.
The state, on the other hand, argued that the only remedy Congress intended for Medicaid violations was federal oversight and the possible withholding of funds — not private lawsuits.
The case was kicked around in lower federal courts before the U.S. Supreme Court took it up. On June 26, SCOTUS handed down a ruling that was devastating news for many Medicaid beneficiaries.
SCOTUS Finds No Private Right of Action
As the Court pointed out, not every federal law gives people the right to sue state officials under §1983. This is especially true for laws like Medicaid, where Congress gives states money in exchange for following certain rules.
For a person to sue under §1983, the law must clearly state that it gives specific rights to individuals, using unmistakable language. Courts require strong proof of this, making it a tough standard to meet. This strict standard protects state sovereignty and ensures states knowingly consent to such suits as a condition of receiving funds.
SCOTUS then applied this standard to the any-qualified-provider provision. They found that the text does not use clear language that creates individual rights — unlike other laws such as the Federal Nursing Home Reform Act (FNHRA), which specifically says residents have the “right to choose a personal attending physician.”
Instead, the Medicaid provision addresses what states must do and how it may help patients and providers. It never directly says patients have a personal right to choose any provider.
Plaintiffs’ Arguments Not Persuasive
The majority rejected several arguments made in favor of allowing private lawsuits to enforce Medicaid provisions. It said that looking at legislative history or the titles of statutes is not enough; what matters is the actual text Congress passed into law.
Second, the Court found it unconvincing that the Medicaid rule was modeled after a Medicare “free choice” provision, because the Medicaid law does not use the same clear, rights-creating language as Medicare.
The plaintiffs had argued that the provision at issue states that a state Medicaid plan must provide that "any individual eligible for medical assistance...may obtain such assistance from any [qualified] provider.”
They argued that this language is “individual-centric” and “mandatory,” implying that it gives individuals the right to enforce the mandate.
But the SCOTUS majority said that it is not enough for a statute to simply use language that focuses on individuals or uses mandatory words like “must” or “shall” to create rights that people can enforce in court. The Court also pointed out that Congress has shown in other laws that it knows how to write clear, rights-giving language, but it chose not to do that in this case.
Finally, the Court rejected policy arguments that private lawsuits are necessary to enforce Medicaid rules. As we’ve explained, the usual way to address state violations is for the federal government to withhold funding. The majority’s attitude is that if Congress wants to create new ways to enforce these rules, it can do so directly.
Abortion Rights Advocates Lament the Ruling
To no one’s surprise, all three liberal justices dissented. Justice Jackson, joined by Justices Sotomayor and Kagan, argued that the majority wrongly narrows the scope of 42 U.S.C. §1983 and undermines Congress’s intent to protect Medicaid recipients’ rights. She stresses that §1983 was designed as a broad remedy to enforce “rights, privileges, or immunities” secured by federal law, including those created by spending-power statutes like Medicaid.
Justice Jackson views the Medicaid “free-choice-of-provider” provision as clearly using individual-focused, mandatory language. She and the other dissenters think Congress intended to create an enforceable right for beneficiaries to choose their healthcare providers. They criticize the majority for demanding an unrealistic level of clarity—essentially requiring Congress to use “magic words.”
The dissenting justices lament that the majority’s approach will harm real people by depriving them of a meaningful way to protect their healthcare choices.
And they aren’t alone; Americans reading the decision, even outside of South Carolina, are fearful of the ruling opening the door for more states to exclude Planned Parenthood health centers from state Medicaid programs.
Arkansas, Texas, and Missouri have already done just that. Democratic Senator Dick Durban of Illinois posted on X: “Blocking Medicaid funds from Planned Parenthood threatens health care for those with few other places to turn.”
Republicans are celebrating the decision as long overdue. Senator Mike Lee of Utah posted: “Americans should never have been forced to pay for abortionists masquerading as ‘healthcare clinics.’”
Related Resources:
- Medicaid Law (FindLaw's Learn About the Law)
- Reproductive Rights: U.S. Supreme Court Cases (FindLaw's Learn About the Law)
- The Law On Healthcare for Transgender Youth Across America (FindLaw's Law and Daily Life)
