Limiting Legal Remedies for Medicaid Prioritizes Politics over Access to Care

In the first U.S. Supreme Court case involving access to abortion after the 2024 election, a 6-3 majority allowed states to block Medicaid patients from choosing their own health care provider. Medina v. Planned Parenthood South Atlantic involved a diabetic Medicaid patient seeking comprehensive health care at Planned Parenthood South Atlantic (PPSA). In 2018, South Carolina blocked PPSA from Medicaid unless it would agree not to provide any abortions. Under federal law, Medicaid already only pays for abortions in cases of rape, incest, or to save the life or health of the patient. But that wasn't enough for South Carolina policymakers, who in 2022 also voted to severely restrict abortion access.

Medina shows that states are emboldened to limit access to medical care after the Dobbs decision overturned the right to access abortion. At the same time, this decision allows states to defy safeguards for people enrolled in federal spending programs, like Medicaid, reflecting a long campaign to weaken the American safety net. Together, the implications for access to medical care across different states cannot be overstated.

Congress protected patients' right to choose their own health care provider in the Medicaid Act to shield access to care and patient autonomy. But after Medina, more states will feel free to limit funding despite these federal protections.

Medicaid's rules mainstream patients into medical care wherever they live. The free choice of provider provision, also called the "any willing provider" or "any qualified provider" rule, was a 1967 response to states' overly restrictive implementation of Medicaid, obligating states to allow patients to pick their own doctor. Until Medina, the vast majority of lower federal courts held that providers and patients could enforce the free choice of provider rule in federal court, but that will no longer be the case.

South Carolina's barring PPSA from Medicaid was part of a larger state movement, including Texas, Louisiana, Missouri, and Arkansas, to limit Planned Parenthood's role in health care for low-income populations by "defunding" it. Nationwide, Planned Parenthood makes medical care available for people that have limited access, including primary care services, such as breast and cervical cancer screenings; sexually transmitted disease screening and care; and contraceptives. No one disputed that South Carolina excluded PPSA solely because it sometimes offers abortions.

In holding for South Carolina, the Court effectively closed federal courthouse doors to patients trying to protect their own access to care. This will affect the roughly 79 million low-income people who rely on Medicaid's public health insurance coverage, which pays for over 40% of all U.S. births, as well as medical needs for children, pregnant patients, elderly people, people with disabilities, and two-thirds of long-term care.

Sixty years of partnership between the Department of Health and Human Services (HHS) and states show Medicaid can cause federal-state conflict, because states do not always implement Medicaid as federal law requires. HHS has power to withhold all or a part of a state's Medicaid funding for noncompliance, a potentially problematic remedy that can weaken the program and hurt beneficiaries and providers. Given how much they rely on Medicaid funds to balance their budgets, states are harmed too if funding is withdrawn.

When providers or patients needed to stop a state from violating the Medicaid Act, they relied on "section 1983," a Civil War-era law that allows for suing individuals "acting under color of law" who violate constitutional or statutory rights. These lawsuits allow courts to issue more precise decisions that directly address state actions, while HHS's power to withhold funding is blunt. The Court reiterated that section 1983 is available to enforce Medicaid rules against noncompliant states just two years ago. Why hear another case so soon? Under the surface is a bigger issue, that states have been making these kinds of claims - unfettered power over regulation of medicine - regularly since Dobbs. South Carolina has been acting as part of a pattern of states challenging federal authority over health care programs, which could undermine the social safety net for everyone, not just people relying on Medicaid.

In the ruling, Justice Gorsuch wrote that HHS could enforce Medicaid rules, but not health care providers or patients, because Medicaid is a federal spending program and the federal government should enforce its own conditions. Most social programs rely on this kind of structure - federal spending offered to states with rules for using the money - and this decision cannot be limited to just Medicaid. Temporary Assistance for Needy Families (TANF), Supplemental Nutrition Assistance Program (SNAP), Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), education, public health, and more could be affected. Despite HHS having power to enforce Medicaid requirements by withholding funds, this is not feasible, not only because withdrawal could be harmful for funding recipients but also because HHS does not have enough staff to police each state's actions for compliance; HHS relies on section 1983 lawsuits to know when states are noncompliant. So, Medina hands states more power, because they have been able to exploit HHS's understaffing, as well as HHS's underenforcement of Medicaid rules that do not align with a presidential administration's policy preferences.

The Court's extreme deference to state regulation of medicine was also displayed in the Skrmetti decision, which allowed Tennessee to ban gender-affirming care for adolescents because the legislature wanted minors to "appreciate their sex." Taken together, these cases mean that states may not only "defund Planned Parenthood," but that they may impose policy preferences on medical care with little fear of federal court oversight. Not only will this curtail patient autonomy, but other politically disfavored kinds of care, such as vaccines, may be on the chopping block. States could go so far as to exclude providers who support firearm safety, or wearing bicycle helmets, with little concern for legal consequences.

Congress created a protected right in Medicaid so that states would not have unfettered power over medical decisions for low-income patients. The ruling for South Carolina does more than ignore Congress's purpose in adding the free choice of provider provision to Medicaid. It gives states significant leeway to regulate medical care beyond abortion. If states can exclude providers regardless of clinical qualifications, health care quality and access for millions of Americans could be jeopardized.

Nicole Huberfeld is Edward R. Utley Professor of Health Law at Boston University School of Law and School of Public Health, Chair of the BU Health Law Program, and Co-Director of the BU Program on Reproductive Justice.