What’s at Stake in the Supreme Court Case Medina v. Planned Parenthood South Atlantic?
On April 2nd, the Supreme Court of the United States will hear oral arguments in Medina v. Planned Parenthood South Atlantic. The case addresses whether Medicaid beneficiaries can seek relief in federal court to enforce Medicaid’s “free-choice of provider provision,” which allows Medicaid beneficiaries to seek care from any provider that is qualified and willing to participate in the program. While the case focuses on this specific question, it has its origins in broader efforts by anti-abortion policymakers to exclude Planned Parenthood clinics from the Medicaid program and, ultimately, eliminate all federal payments to Planned Parenthood centers. In this brief, we describe the case, the Medicaid policies underlying it, and potential implications for Medicaid beneficiaries’ access to reproductive health services.
What is the case in front of the Supreme Court about?
The Supreme Court’s review of this case is limited to one question: Can a Medicaid beneficiary bring a civil action to enforce the Medicaid Act’s free choice of provider? This question is similar to one that the Court decided in 2023 (Health and Hospital Corp of Marion County v. Talevski ) when it ruled (7-2) that patients do have a private right of action to enforce certain conditions that federal Medicaid law imposes on states and health care providers. However, the current case involves a different provision of federal law relating to free choice of provider under the Medicaid Act. Planned Parenthood and the individual beneficiary who has brought this case take the position that Medicaid beneficiaries meet the requirements to sue in order to enforce the free choice of provider provision. The Trump administration has weighed in on the side of South Carolina, contending that Medicaid beneficiaries should not be permitted to bring an action to enforce this provision.
In 2018, South Carolina’s Governor McMaster (R) issued an executive order prohibiting any clinic that provides abortion care from participating in the state’s Medicaid program. The order states that the state funds used to reimburse providers could be used to indirectly subsidize abortion care even though Medicaid only pays for non-abortion family planning services. The executive order had a direct impact on the Planned Parenthood clinics that offer abortion services in the state (South Carolina limits abortion to up to six weeks of pregnancy) but also offer enrollees other Medicaid-covered services including contraceptive care and STI screening and treatment. The state has historically reimbursed these providers for the non-abortion medical care they provide to Medicaid enrollees just like it pays for all other medical care. The federal Hyde Amendment bans the use of federal funds (including Medicaid) from being used to pay for abortions unless the pregnancy is a result of rape or incest or endangers the life of the pregnant person.
States operate Medicaid programs under federal guidance, and one of the federal provisions of the Medicaid law is known as free choice of provider. This provision states that “A State plan for medical assistance must… provide that any individual eligible for medical assistance… 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.” Additionally, because many states require Medicaid beneficiaries to enroll in managed care, limiting their care to a defined network of providers, federal law states that beneficiaries may seek care from any Medicaid provider for family planning services specifically, even those outside the plan network.
The larger context for this case involves how a state determines who is a qualified provider, even though the Supreme Court is more narrowly focusing on private right of action. The statute does not define the word “qualified,” but longstanding federal regulations, recognize states’ authority to “set reasonable standards relating to the qualifications of providers.” The final lines of the regulation say that States need not provide payments to providers with certain felony convictions. The regulations and a separate provision contemplate that “[i]n addition to any other authority, a State may exclude” any provider from Medicaid for certain reasons “for which the Secretary could exclude” the provider from participating in Medicare.
In 2016, in a “Dear Medicaid Director letter” issued during the Obama administration, CMS wrote that states have the authority to set standards that providers must meet, but to disqualify a willing provider, the state must have a legitimate reason such as concerns about the fitness of the provider to meet the standards or evidence of fraud. It went on to say that states cannot target a specific provider and “The failure of a state to apply otherwise reasonable standards in an evenhanded manner may suggest such targeting.” CMS went on to say that “states may not deny qualification to family planning providers…solely because they separately provide…abortion or another service that the state does not approve of.” This letter was rescinded by the Trump administration in 2018. Whether it be through the Courts or through administrative actions, this issue will likely continue to be debated and legally challenged for the foreseeable future.
The Supreme Court, however, is only considering whether Medicaid beneficiaries have the right to bring a case to enforce their right to choose their provider. The Court is not considering whether South Carolina acted properly when it excluded Planned Parenthood from its Medicaid program, deeming them “unqualified” because they provide abortion services as well as other reproductive health care services. If the Supreme Court finds that Medicaid beneficiaries have the right to bring an action to enforce their right to choose any provider, the case will then go back down to the district court to determine whether South Carolina acted within its authority to exclude Planned Parenthood as a nonqualified provider. If the Supreme Court rules that Medicaid beneficiaries do not have a private right of action, then Planned Parenthood itself could appeal South Carolina’s decision that found them to be an unqualified provider.
How have courts ruled about private right of action for Medicaid beneficiaries in other cases?
A civil rights statute, Section 1983, has long provided a mechanism for individuals to enforce the rights provided to them under federal programs, including Medicaid. There is a long history of litigation related to private enforcement of the Medicaid Act. While courts have affirmed the authority for individuals to use Section 1983 to protect Medicaid rights, the Supreme Court has issued decisions that have narrowed this authority. Currently there is a three-pronged test (pursuant to the cases Blessing v Freestone (1997), Gonzaga University v. Doe (2002), and Health & Hosp. Corp of Marion County v. Talevski (2023)) based on legal precedent that courts use to evaluate whether a federal law establishes an enforceable right:
- whether the plaintiff is an intended beneficiary of the statute;
- whether the plaintiff’s asserted interests are specific enough to be enforced; and
- whether the statute imposes a binding obligation on the State.
In Talevski, the most recent Supreme Court case to consider this right, the high court reaffirmed the holdings in Gonzaga that a statutory provision is enforceable under Section 1983 when the provision is “phrased in terms of the persons benefits” and contains “right-creating individual centric language with an unmistakable focus on the benefited class.”
Federal circuit courts have generally upheld private enforcement of rights for Medicaid enrollees. Before the Supreme Court Talevski ruling in 2023, there was a split among circuit court rulings. In 2019 there were four circuit court opinions that all ruled in favor of beneficiaries’ right to enforce Medicaid provisions. However, in 2020, three of four circuit court decisions did not rule in favor of Medicaid enrollees, including one decision from the 5th Circuit Court of Appeals which ruled in favor of Texas’ decision to exclude Planned Parenthood. Until the Medina case, the Supreme Court had previously refused to review multiple cases in which Planned Parenthood patients were found to have an enforceable right. An earlier version of the Medina case, Planned Parenthood South Atlantic v. Baker, went up to the Supreme Court but was denied review. This is the first time the current configuration of the Supreme Court will hear a case involving Planned Parenthood.
While this case is narrowly focused on whether Medicaid beneficiaries have the right to sue to enforce their right to choose any willing, qualified provider, the Supreme Court’s decision will have implications for the many states wishing to exclude providers, such as Planned Parenthood, based on abortion politics and not based on clinical qualifications to provide medical services. If Medicaid beneficiaries cannot bring an action to enforce the free choice of provider provision, then states will have greater latitude to exclude providers, such as Planned Parenthood, based on political objections.
What does this case mean for Medicaid beneficiaries?
This case has the potential to curtail low-income individuals’ access to preventive reproductive health care in South Carolina and potentially in many states in the nation. The Medicaid program covers one in five reproductive age women and is the largest source of coverage for women with low incomes, covering over four in ten (Figure 1). All state Medicaid programs must cover family planning services, which includes contraceptive care plus a range of related services such as physical exams, cancer screenings, pregnancy testing and counseling, and screenings for other conditions. Medicaid is an essential source of financing for safety-net clinics and is widely considered to be the largest single public payer of family planning services. KFF research has found that specialty reproductive health care clinics such as Planned Parenthood centers offer a broader range of services to their patients compared to non-specialized clinics.
Other states are likely to follow suit if the Court rules in South Carolina’s favor. In fact, several other states, such as Texas, Arkansas, Indiana, and Missouri have tried to keep Planned Parenthood clinics out of their Medicaid networks, and while some of these efforts were blocked by CMS and courts because they violate the free choice of provider requirements, there have been exceptions. Federal courts upheld Arkansas and Texas decisions excluding Planned Parenthood from their Medicaid programs. South Carolina filed a waiver application to CMS during the first Trump Administration to exclude Planned Parenthood clinics from their Medicaid program, and Tennessee also has a similar waiver pending. No action has been taken to date on these waivers.
Blocking Planned Parenthood from receiving Medicaid reimbursements or other public funds has been shown to reduce low-income women’s access to contraceptives. In 2013, Texas replaced its Medicaid family planning program with a 100% state funded program that excluded Planned Parenthood as a participating provider. Following the policy change, there was a sizable drop in Medicaid claims for long-acting contraceptives such as IUDs or implants, and injectable contraceptives and an increase in Medicaid-funded births.
What is next?
The federal Solicitor General was granted approval to participate in oral arguments and has taken the position of South Carolina in this case. The Supreme Court will hear oral arguments on April 2nd and is expected to issue a ruling by the end of the term in June 2025.