Medicaid and beneficiary enforcement: Maintaining state compliance with federal availability requirements

Yale Law Journal

Volumn 117, Issue 7, 2008, Pages 1498-1547

  Donenberg, Jon ^a  

^a YALE UNIVERSITY   (United States)

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[No Author keywords available]

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EID: 44949255304     PISSN: 00440094     EISSN: None     Source Type: Journal    
DOI: 10.2307/20454686     Document Type: Article

References (340)

1. See RAND E. ROSENBLATT, SYLVIA A. LAW & SARA ROSENBAUM, LAW AND THE AMERICAN HEALTH CARE SYSTEM 15-16 (1997) (noting how the various limitations of the original program led Medicaid to reach only "one half or less of families with incomes below the federal poverty line");
2. see also id. at 410-21 (providing additional history on the massive growdi of the Medicaid program since its inception).
3. ROBIN RUDOWITZ & ANDY SCHNEIDER, KAISER COMM'N ON MEDICAID AND THE UNINSURED, THE NUTS AND BOLTS OF MAKING MEDICAID POLICY CHANGES : AN OVERVIEW AND A LOOK AT THE DEFICIT REDUCTION ACT 4 (2006), available at http://www.kff.org/medicaid/upload/7550.pdf.
4. 42 U.S.C. §§ 1396-1396v (2000).
5. Medicaid: Centers for Medicare and Medicaid Services, http://www.cms.hhs.gov/home/medicaid.asp (last visited Mar. 6, 2008).
6. See Michael A. Platt, Comment, Westside Mothers and Medicaid: Will This Mean the End of Private Enforcement of Federal Funding Conditions Using Section 1983?, 51 AM. U. L. REV. 273, 297-307 (2001).
7. Id.
8. See Bruce J. Casino, Federal Grants-In-Aid: Evolution, Crisis, and Future, 20 URB. LAW. 25, 40 (1988) (arguing that financial strain on the states means that their participation in federal grants-in-aid programs is de facto compulsory);
9. see also James F. Blumstein & Frank A. Sloan, Health Care Reform Through Medicaid Managed Care: Tennessee (TennCare) as a Case Study and a Paradigm, 53 VAND. L. REV. 125, 141-44 (2000) (discussing the effects of political "lock-in" that make it increasingly difficult for states to scale back on Medicaid funding).
10. 42 C.F.R. § 430.10 (2007).
11. See Frederick H. Cohen, An Unfulfilled Promise of the Medicaid Act: Enforcing Medicaid Recipients' Right to Health Care, 17 LOY. CONSUMER L. REV. 375, 390 (2005) (noting that "[m]any states . . . are under-funding their Medicaid programs" in violation of their obligations under the federal statute).
12. See generally Edward A. Tomlinson & Jerry L. Mashaw, The Enforcement of Federal Standards in Grant-in-Aid Programs: Suggestions for Beneficiary Involvement, 58 VA. L. REV. 600, 619-21 (1972) (discussing the relative ineffectiveness of federal agencies at enforcing statutory requirements).
13. 42 U.S.C. § 1396c (2000).
14. Tomlinson & Mashaw, supra note 9, at 619-21.
15. Lisa E. Key, Private Enforcement of Federal Funding Conditions Under § 1983: The Supreme Court's Failure To Adhere to the Doctrine of Separation of Powers, 29 U.C. DAVIS L. REV. 283, 293 (1996);
16. see also Tomlinson & Mashaw, supra note 9, at 620 ("The posture of the federal agency toward its grantees is not generally that of a referee calling fouls, but mat of a coach giving support in the form of cash and expertise.").
17. See Key, supra note 12, at 292-93.
18. See id. at 293;
19. Tomlinson & Mashaw, supra note 9, at 618-19.
20. 42 U.S.C. § 1983 (2000).
21. 448 U.S. 1 (1980).
22. 496 U.S. 498 (1990).
23. See Platt, supra note 5, at 276 & n.10.
24. It is not unusual for Congress to create pathways for private litigation to ensure compliance with the requirements of federal statutes. Congress frequently creates citizen-standing provisions that authorize private individuals to sue federal agencies for noncompliance with the law. See, e.g., Clean Water Act § 505, 33 U.S.C. § 1365 (2000).
25. In areas where enforcement is particularly difficult, the government sometimes creates incentives for such lawsuits by individuals better situated than the federal government to ensure compliance with federal policy norms. See, e.g., Marc S. Raspanti & David M. Laigaie, Current Practice and Procedure Under the Whistleblower Provisions of the Federal False Claims Act, 71 TEMP. L. REV. 23 (1998) (discussing the development and efficacy of qui tarn actions to incentivize whistle blowing when contractors defraud the government).
26. See Wyatt v. Cole, 504 U.S. 158, 161 (1992) (identifying a main animating purpose of § 1983 as "deter[ring] state actors from using the badge of their authority to deprive individuals of their federally guaranteed rights and to provide relief to victims if such deterrence fails") ;
27. see also Richardson v. McKnight, 521 U.S. 399, 402-03, 412 (1997) ;
28. Robertson v. Wegmann, 436 U.S. 584, 590-91 (1978).
29. See Deficit Reduction Act of 2005, Pub. L. No. 109-171, 120 Stat. 4 (2006) (codified in scattered sections of 42 U.S.C.);
30. see also ANDY SCHNEIDER & RACHEL GARFIELD, KAISER COMM'N ON MEDICAID & THE UNINSURED, THE MEDICAID RESOURCE BOOK 49, 54-57 (2002), available at http://www.kff.org/medicaid/loader.cfm?url=/commonspot/security/getfile. cfm&PageID=14260 (describing the DRA's new benefits structure).
31. See 42 U.S.C. § 1396a(a)(10)(A) (2000).
32. Id. § 1396a(a)(3).
33. Pub. L. No. 109-171, 120 Stat. 4 (2006) (codified in scattered sections of 42 U.S.C.).
34. See Gonzaga Univ. v. Doe, 536 U.S. 273, 283 (2002).
35. The traditional Medicaid benefits are summarized in 42 U.S.C. § 1396d(a) (2000). Section 1396a(a)(10)(A) indicates those provisions of § 1396d(a) that describe mandatory services; the remainder of § 1396d(a) defines optional services. See also SCHNEIDER & GARFIELD, supra note 21, at 54-57.
36. 42 U.S.C. § 1396d(a)(5)(A) (2000).
37. Id. § 1396d(a)(3).
38. Id. § 1396d(a)(1).
39. Id. § 1396d(a)(4)(B).
40. Id. § 1396d(a)(4)(A).
41. See Jeffrey R. Brown, Norma B. Coe & Amy Finkelstein, Medicaid Crowd-Out of Private Long-Term Care Insurance Demand: Evidence from the Health and Retirement Survey (2007), available at http://www.aeaweb.org/annual_mtg_papers/2007/0107_1300_0701.pdf.
42. 42 U.S.C. § 1396d(a)(12) (2000).
43. Id. § 1396d(a)(19).
44. The Kaiser Commission on Medicaid and the Uninsured has estimated that so-called optional services now account for sixty percent of all Medicaid expenditures. KAISER COMM'N ON MEDICAID & THE UNINSURED, DEFICIT REDUCTION ACT OF 2005: IMPLICATIONS FOR MEDICAID 3 (2006) [hereinafter KAISER DRA REPORT], available at https://www.aucd.org/docs/policy/medicaid/kaiser_medicaid_dra_2005_020106.pdf.
45. Diane Rowland & James R. Tallon Jr., Medicaid: Lessons from a Decade, HEALTH AFF., Jan./Feb. 2003, at 138, 140-41.
46. See, e.g., Dayna Bowen Matthew, The "New Federalism" Approach to Medicaid: Empirical Evidence that Ceding Inherently Federal Authority to the States Harms Public Health, 90 KY. L.J. 973, 990-91 (2002) (presenting data on enrollment and expenditure disparities across sample states).
47. 42 C.F.R. § 430.10 (2007).
48. Authority is granted to the HHS Secretary for several different types of waivers. See, e.g., 42 U.S.C. §§ 1315(a), 1396n(b), 1396n(c) (2000).
49. 42 C.F.R. § 430.12(c)(ii) (2007). States are also required to submit amendments to instantiate any modifications required by changes in federal law, regulations, policy interpretations, or court decisions. Id. § 430.12(c) (i).
50. 42 U.S.C. § 1396a(b) (2000).
51. Id. § 1396a(a).
52. RUDOWTTZ & SCHNEIDER, supra note 2, at 9.
53. See 42 C.F.R. § 440.230(b) (2007);
54. see also Alexander v. Choate, 469 U.S. 287, 289 & n.1 (1985).
55. Deficit Reduction Act of 2005, Pub. L. No. 109-171, 120 Stat. 4 (2006) (codified in scattered sections of 42 U.S.C.).
56. In signing the DRA, President Bush noted that the bill was meant to promote restraint in federal spending dirough "difficult choices" made "[b]y setting priorities and making sure tax dollars are spent wisely." President George W. Bush, Statement of the President upon Signing S.1932, Deficit Reduction Act of 2005 (Feb. 8, 2006), available at http://www.whitehouse.gov/news/releases/2006/02/20060208-8.html.
57. See CONGRESSIONAL BUDGET OFFICE, CONGRESSIONAL BUDGET OFFICE COST ESTIMATE: S.1932 DEFICIT REDUCTION ACT OF 2005, at 1 (2006) [hereinafter CBO ESTIMATE].
58. Id. at 34.
59. Deficit Reduction Act §§ 6001-6203, 120 Stat, at 54.
60. See CBO ESTIMATE, supra note 47, at 40.
61. Deficit Reduction Act § 6041, 120 Stat. at 81-82.
62. See 42 U.S.C.A. § 13960-1(a)(2)(B) (West Supp. 2007) (outlining state options for providing for these two cost-sharing mechanisms).
63. See CBO ESTIMATE, supra note 47, at 40.
64. Although some states have imposed greater levels of cost sharing than these nominal limits through CMS waivers, the majority of enrollees did not pay any cost sharing prior to the DRA. Id.
65. See 42 U.S.C.A. § 13960-1(b) (West Supp. 2007).
66. The degree to which states are granted flexibility in distributing cost sharing across different types of services is particularly significant. While the DRA imposes caps on the total percentage of family income that can be consumed by cost sharing generally, cost sharing required for individual services can be much greater-one-tenth of the total cost per service for individuals between 100% and 150% of the federal poverty line, and one-fifth of the total cost for individuals above 150% of the federal poverty line. Id.
67. 42 U.S.C.A. § 13960-1(a)(2)(A) (West Supp. 2007).
68. See CBO ESTIMATE, supra note 47, at 40.
69. States can now require premiums from individuals with incomes in excess of 150% of the federal poverty line, so long as the total cost of both premiums and cost sharing does not exceed five percent of a family's total income. 42 U.S.C.A. § 13960-1(b)(2) (A) (West Supp. 2007).
70. The imposition of both premiums and copayments is limited to certain beneficiary categories and certain types of items and services. See, e.g., id. § 13960-1(b)(3)(B)
71. (exempting most eligible beneficiaries under the age of eighteen, women who are specifically guaranteed access to certain services, pregnant women, terminally ill individuals receiving hospice care, and certain categories of institutionalized patients from DRA cost sharing); id. § 13960-1(b)(3)(A) (exempting the same group from premiums).
72. See, e.g., SAMANTHA ARTIGA & MOLLY O'MALLEY, HENRY J. KAISER FOUND., INCREASING PREMIUMS AND COST SHARING IN MEDICAID AND SCHIP: RECENT STATE EXPERIENCES (2005), available at http://www.kff.org/medicaid/ upload/Increasing-Premiums-and-Cost-Sharing-in-Medicaid-and-SCHIP-Recent-State- Experiences-Issue-Paper.pdf (noting that the effect of premium and cost-sharing increases via waiver increased withdrawals from state Medicaid programs in Oregon, Vermont, Rhode Island, Maryland, and Utah);
73. LEIGHTON KU, CTR. ON BUDGET & POLICY PRIORITIES, CHARGING THE POOR MORE FOR HEALTH CARE: COST-SHARING IN MEDICAID (2003), available at http://www.cbpp.org/5-7- o3health.pdf (surveying empirical research and concluding that premiums and cost sharing have negative effects on enrollment rates in Medicaid);
74. see also CBO ESTIMATE, supra note 47, at 41.
75. Leighton Ku & Teresa A. Coughlin, Sliding-Scale Premium Health Insurance Programs: Four States' Experiences, 36 INQUIRY 471 (2000).
76. JOHN MCCONNELL & NEAL WALLACE, OFFICE FOR OR. HEALTH POLICY & RESEARCH, IMPACT OF PREMIUM CHANGES IN THE OREGON HEALTH PLAN (2004), available at http://www.oregon.gov/DAS/OHPPR/RSCH/docs/ImpaasPremiums. pdf.
77. CTR. OF CHILD & FAMILY HEALTH, R.I. DEP'T OF HUMAN SERVS., RESULTS OF RITE CARE PREMIUM FOLLOW-UP SURVEY 1 (2003), available at http://www.ritecare.ri.gov/ documents/reports_publications/ResultsRC_Prem_Surv2003.pdf.
78. OFFICE OF HEALTH CARE STATISTICS, UTAH DEP'T OF HEALTH, UTAH PRIMARY CARE NETWORK DISENROLLMENT REPORT, at ii, (2004), available at http://health.utah.gov/hda/Reports/ PCN%20Disenrollment.pdf.
79. MATTHEW J. CARLSON & BILL WRIGHT, OFFICE FOR OR. HEALTH POLICY & RESEARCH, THE IMPACT OF PROGRAM CHANGES ON ENROLLMENT, ACCESS, AND UTILIZATION IN THE OREGON HEALTH PLAN STANDARD POPULATION 8 (2005), available at http://www.oregon.gov/OHPPR/ RSCH/docs/OHREC_Cohortflwup_03_05_rpt.pdf.
80. Id. at 9.
81. Id. at 13.
82. See, e.g., Henry Aaron & William B. Schwartz, Rationing Health Care: The Choice Before Us, 247 Sci. 418, 419 (1990).
83. 42 U.S.C. § 13960(e) (2000);
84. see also CBO ESTIMATE, supra note 47, at 40.
85. 42 U.S.C. § 13960(c)(3).
86. 42 U.S.C.A. § 13960-(d)(1) (West Supp. 2007).
87. Id.
88. Id. § 13960-1(d)(2).
89. Id. § 13960-1(b)(3)(B)(vi).
90. No similar restriction, however, is found in the DRA with respect to the imposition of premiums. See id. § 13960-1(b)(3)(A).
91. Id. § 13960-1(e)(1).
92. Cost sharing here is somewhat limited by notice requirements and the need for an alternate nonemergency services provider that is "actually available and accessible." Id. § 13960-1(6)(1)(A), (B).
93. In addition, it is limited to twice the nominal amount for individuals with family incomes between 100% and 150% of the federal poverty line, id. § 13960-1(e)(2)(A),
94. and to the nominal amount in the case of individuals otherwise exempt from the new, higher limits on cost sharing. Id. § 13960-1(e)(2)(B).
95. For eligible beneficiaries outside the application of the nominal cost-sharing restrictions, aggregate cost sharing remains capped at five percent. Id. § 13960-1(e)(2)(C).
96. See 42 U.S.C. § 1396a(10)(A) (2000) (indicating which services under § 1396d(a) must be provided to all eligible beneficiaries);
97. see also 42 U.S.C. § 1396a(a)(10) (2000) (defining mandatory and optional populations).
98. See, e.g., 42 U.S.C. §§ 1396a(a)(10), 1396d(a) (2000).
99. See KAISER DRA REPORT, supra note 35, at 2-3.
100. CBO ESTIMATE, supra note 47, at 41.
101. 42 U.S.C. § 1396a(a)(1) (2000).
102. Id. § 1396a(a)(10)(B).
103. 42 U.S.C.A. § 1396u-7(a)(1)(A) (West Supp. 2007) (indicating mat state options to exercise increased discretion in the provision and structuring of benefits apply "[notwithstanding any other provision of mis subchapter").
104. Id.
105. Id. § 1396u-7(b)(1)(A).
106. For the requirements of the FEHBP preferred provider plan, see 5 U.S.C. § 8903(1) (2000).
107. 42 U.S.C.A § 1396u-7(b)(1)(B) (West Supp. 2007).
108. Id. § 1396u-7(b)(1)(C).
109. Id. § 1396u-7(b)(2).
110. Id. § 1396u-7(b)(1)(D).
111. See Ctrs. for Medicare & Medicaid Servs., Alternative Benefit Packages, http://www.cms.hhs.gov/DeficitReductionAct/21_Benefits.asp (last visited Mar. 6, 2008) (providing submissions materials from those states that have had SPAs approved to implement cost sharing, premiums, and benchmark and/or benchmark-equivalent plans under the terms of the DRA).
112. See 42 U.S.C.A. § 1396u-7(a)(2)(A) (West Supp. 2007).
113. Under the DRA, states can require Medicaid beneficiaries who are subject to the new benefits options to enroll in one of mese benchmark or benchmark-equivalent plans and can also apply the restrictive new packages "to individuals within 1 or more groups of such individuals." Id. (emphasis added).
114. For a list of exempt enrollee groups, see id. § 1396u-7(a)(2)(B) (West Supp. 2007);
115. and id. § 1396u-7(a)(2)(C)(ii).
116. See Letter from Ctrs. for Medicare & Medicaid Servs. Dir. to State Medicaid Dirs., SMDL #06-008 (Mar. 31, 2006).
117. 42 U.S.C.A § 1396u-7(a)(1)(B) (West Supp. 2007).
118. Id. § 1396u-7(a)(2)(A).
119. Timothy Stolzfus Jost, Our Broken Health Care System and How To Fix It: An Essay on Health Law and Policy, 41 WAKE FOREST L. REV. 537, 614 & n.440 (2006);
120. see also KAISER DRA REPORT, supra note 33, at 3 (assessing the impact of benefit reductions on millions of enrollees);
121. Sara Rosenbaum, Medicaid at Forty: Revisiting Structure and Meaning in a Post-Deficit Reduction Act Era, 9 J. HEALTH CARE L. & POL'Y 5, 35 (2006) ("[T]he Deficit Reduction Act of 2005 marks a new chapter in the life of the Medicaid program by introducing certain fundamental changes into program design; these changes in turn hold the potential for a far-reaching re-formulation of the rules of coverage and state plan administration and, as a result, legal duties and rights.").
122. Timomy Stolzfus Jost, The Tenuous Nature of the Medicaid Entitlement, 22 HEALTH AFF. 145, 151 (2003).
123. Indeed, many states are constitutionally prohibited from running deficits, forcing them to decrease expenditures at the same time that overall Medicaid costs are increasing. Id.;
124. see also Rowland & Talion, supra note 36, at 141-42 ("States have a love-hate relationship with their Medicaid programs - expanding them in good times and contracting them in bad times.").
125. See NAT'L ASS'N OF STATE BUDGET OFFICERS, 2001 STATE EXPENDITURE REPORT 4 (2002), available at http://www.nasbo.org/Publications/ PDFs/nasbo2001exrep.pdf.
126. David A. Super, Rethinking Fiscal Federalism, 118 HARV. L. REV. 2544, 2609-10 (2005).
127. See generally AM. ACAD. OF PEDIATRICS, STATE LEGISLATION REPORT (2007) (detailing legislative efforts by states toward expanding their safety nets under Medicaid and the related SCHIP program), available at http://www.aap.org/advocacy/ statelegrpt.pdf.
128. See Letter from Sen. Barbara A. Mikulski et al. to Sen. Max Baucus, Chairman, Senate Finance Comm. and Sen. Charles Grassley, Ranking Member, Senate Finance Comm. (Jan. 29, 2008), available at http://mikulski.senate.gov/record.cfm?id=29i443 (describing an effort by Democratic senators to provide targeted increases in Medicaid funding to states on the eve of significant projected economic downturn since "Medicaid and other social programs are the first in line for cuts in cash-strapped states desperate for revenue").
129. See supra notes 10-12 and accompanying text.
130. See generally Pennhurst State Sch. & Hosp. v. Halderman, 451 U.S. 1 (1981) (requiring that any conditions placed on the receipt of federal funds be clearly stated).
131. 42 U.S.C. § 1983 (2000).
132. See, e.g., Platt, supra note 5, at 276 & n.10;
133. see also Sasha Samberg-Champion, Note, How To Read Gonzaga: Laying the Seeds of a Coherent Section 1983 Jurisprudence, 103 COLUM. L. REV. 1838, 1838 (2003).
134. 536 U.S. 273, 283-84 (2002).
135. See infra note 132 and accompanying text.
136. See, e.g., Gonzaga, 536 U.S. at 284.
137. 448 U.S. 1 (1979).
138. See RICHARD H. FALLON, JR. , DANIEL J. MELTZER & DAVID L. SHAPIRO, HART & WECHSLER'S THE FEDERAL COURTS AND THE FEDERAL SYSTEM 1082 & n.10 (5dl ed. 2003) (noting a substantial increase in nonprisoner "civil rights" actions, over half of which appear to relate to rights claimed to be conferred by specific federal statutes).
139. 496 U.S. 498 (1990).
140. See 42 U.S.C. § 1390a(a)(13)(A) (1994).
141. This provision, known as the Boren Amendment, is situated in the statute in such a way that its introductory clause- "[a] State plan for medical assistance must ... provide" -is identical to the introductory language of § 1396a(a)(10) and the other mandatory provision components of § 1396a(a). It was repealed in 1997. See Balanced Budget Act of 1997, Pub. L. No. 105-33, § 4711(a)(1), 111 Stat. 251, 507-08.
142. See Pediatric Specialty Care, Inc. v. Ark. Dep't of Human Servs., 293 F.3d 472 (8th Cir. 2002);
143. Westside Mothers v. Haveman, 289 F.3d 852 (6th Cir. 2002);
144. Miller v. Whitburn, 10 F.3d 1315 (7th Cir. 1993). For post-Gonzaga cases, see infra note 133 and accompanying text.
145. See Gonzaga Univ. v. Doe, 536 U.S. 273, 281 (2002) (citing cases mat have "rejected attempts to infer enforceable rights from Spending Clause statutes").
146. 503 U.S. 347 (1992).
147. Id. at 361-63.
148. See 42 U.S.C. § 1320a-2 (2000);
149. see also Samberg-Champion, supra note 104, at 1850-52 (2003).
150. 520 U.S. 329 (1997) (internal citations omitted).
151. Id. at 340-41.
152. See Samberg-Champion, supra note 104, at 1851-52.
153. 536 U.S. 273 (2002).
154. Id. at 287 (2002)
155. (quoting Alexander v. Sandoval, 532 U.S. 275, 288 (2001));
156. see also Sandoval, 532 U.S. at 289 ("Statutes that focus on the person regulated rather than the individuals protected create 'no implication of an intent to confer rights on a particular class of persons.'"
157. (quoting California v. Sierra Club, 451 U.S. 287, 294 (1981)).
158. Gonzaga, 536 U.S. at 288
159. (quotingBlessing, 520 U.S. at 343).
160. Id.
161. (quoting Blessing, 520 U.S. at 335, 343).
162. See id. (comparing the "text and structure" of the provision at issue to a neighboring provision in the statute).
163. Id. at 290.
164. See Wilder v. Va. Hosp. Ass'n, 496 U.S. 498, 505-09 (1990).
165. See Gonzaga, 536 U.S. at 283.
166. See, e.g., Bradford C. Mank, Suing Under § 1983: The Future After Gonzaga University v. Doe, 39 HOUS. L. REV. 1417, 1418-19 (2003);
167. Samberg-Champion, supra note 104, at 1839.
168. See The Supreme Court, 2001 Term-Leading Cases, 116 HARV. L. REV. 200, 381 (2002);
169. Erwin Chemerinsky, Limiting Suits To Enforce Federal Laws, TRIAL, Jan. 2003, at 70.
170. See Brian J. Dunne, Enforcement of the Medicaid Act Under 42 U.S.C. § 1983 After Gonzaga University v. Doe: The "Dispassionate Lens" Examined, 74 U. CHI. L. REV. 991, 1001-12 (2007);
171. Jane Perkins, Natl Health Law Prog., Issue Brief: Update on §1983 Enforcement of the Medicaid Act 3 (Jan. 2007), http://www.healdilaw.org/library. cfm?fa=download&resourceID=945i6&print.
172. See, e.g., Pa. Pharmacists Ass'n v. Houstoun, 283 F.3d 531, 543-44 (3d Cir. 2002);
173. Evergreen Presbyterian Ministries, Inc. v. Hood, 235 F.3d 908, 927-28 (5th Cir. 2000);
174. Visiting Nurse Ass'n v. Bullen, 93 F.3d 997,1004 n.7 (1st Cir. 1996);
175. Ark. Med. Soc'y, Inc. v. Reynolds, 6 F.3d 519, 528 (8th Cir. 1993).
176. For circuits refusing to apply § 1983 in the equal access provision context, see Mandy R. ex rel. Mr. & Mrs. R. v. Owens, 464 F.3d 1139 (10th Cir. 2006);
177. Westside Mothers v. Olszewski, 454 F.3d 532 (6th Cir. 2006) ;
178. Sanchez v. Johnson, 416 F.3d 1051 (9th Cir. 2005) ;
179. Long Term Care Pharm. Alliance v. Ferguson, 362 F.3d 50 (1st Cir. 2004).
180. This result can be compared with Pediatric Specialty Care, Inc. v. Ark. Dep't of Human Servs., 443 F.3d 1005 (8th Cir. 2006),
181. which upheld a prior circuit ruling allowing § 1983 lawsuits under the equal access provision. For more on the efforts of the federal courts with regard to § 1983 Medicaid enforcement lawsuits, see Dunne, supra note 130, at 1003-11.
182. See Westside Mothers, 454 F.3d at 532;
183. Watson v. Weeks, 436 F.3d 1152 (9th Cir. 2006), cert. denied sub nom. Goldberg v. Watson, 127 S. Ct. 598 (2006);
184. S.D. ex rel. Dickson v. Hood, 391 F.3d 581 (5th Cir. 2004);
185. Sabree ex rel. Sabree v. Richman, 367 F.3d 180 (3d Cir. 2004).
186. Watson, 436 F.3d at 1161.
187. See Gonzaga Univ. v. Doe, 536 U.S. 273, 280 (2002).
188. The statutory language regarding benefit restructuring, cost sharing, and premiums specifically states that it is inapplicable to certain beneficiaries. See supra notes 59, 91 and accompanying text.
189. See Spry v. Thompson, 487 F.3d 1272 (9th Cir. 2007);
190. Katie A. ex rel. Ludin v. L.A. County, 481 F.3d 1150 (9th Cir. 2007);
191. Okla. Chapter of the Am. Acad. of Pediatrics v. Fogarty, 472 F.3d 1208 (10th Cir. 2007);
192. Owens, 464 F.3d 1139;
193. Westside Mothers, 454 F.3d 532.
194. See Ludin, 481 F.3d at 1153 n.7 (indicating that the state did not contest the applicability of § 1983 to enforce mandatory benefits).
195. In Fogarty, 472 F.3d at 1212 n.1, and Owens, 464 F.3d at 1143, the Tenth Circuit "assume[d] without deciding" that § 1983 provided a cause of action to the Medicaid plaintiffs. Apparently, neither party contested the applicability of the statute as it applied to the benefits portion of the Medicaid statute.
196. See Brief of the Cross-Appellee at 4, Spry v. Thompson, 487 F.3d 1272 (9th Cir. 2007) (No. 04-35750) (arguing that § 1983 does not confer a right of action on the plaintiffs by analyzing the pre-DRA distinction between mandatory and optional benefit categories).
197. The Ninth Circuit also referenced its pre-DRA view of the "availability" provision in dicta found in Ball v. Rodgers, 492 F.3d 1094, 1109 (9th Cir. 2007), again without apparent awareness of the new Medicaid framework occasioned by the DRA.
198. Westside Mothers, 454 F.3d at 539-41.
199. Although described in terms of congressional intent, the Court's rights inquiry under Gonzaga, like its inquiry in the analogous implied cause of action cases, is less about actual intent in an individual case and more about imposing a clear statement rule on Congress with respect to creating enforceable rights.
200. See Alexander v. Sandoval, 532 U.S. 275, 288 (2001) (refusing to find an implied cause of action even when it seemed clear that the enacting Congress believed that contemporaneous courts would understand the statute to confer such a right).
201. Since Gonzaga emphasizes that the § 1983 inquiry should "not differ from its [inquiry] in discerning whether personal rights exist in the implied right of action context," Gonzaga Univ. v. Doe, 536 U.S. 273, 285 (2002), courts can be expected to apply the same sort of presumption against finding a right where Congress does not clearly and unambiguously state its intent to confer one.
202. 42 U.S.C. § 1396a(a)(10)(A)(i) (2000) (emphasis added).
203. 20 U.S.C. § 1681(a) (2000);
204. U.S.C. § 2000d (2000).
205. Gonzaga, 536 U.S. at 284 (emphasis omitted) (quoting Cannon v. Univ. of Chi., 441 U.S. 677, 691 (1979)).
206. 42 U.S.C.A. § 1396u-7(a)(1)(A) (West Supp. 2007).
207. Gonzaga, 536 U.S. at 282 (quoting Blessing v. Freestone, 520 U.S. 329, 340-41 (1997)).
208. 42 U.S.C. § 13960(e) (2000).
209. Id. § 13960(c)(3).
210. 42 U.S.C.A. § 13960-1(d) (West Supp. 2007).
211. See Gonzaga, 536 U.S. at 280.
212. 42 U.S.C.A. § 1396u-7(b)(1)(D) (West Supp. 2007). This flexibility would seem to be cabined only by constitutional constraints in the equal protection context.
213. See Gonzaga, 536 U.S. at 285-86.
214. Id. at 290.
215. It should be emphasized that while the Gonzaga Court looked to legislative history to bolster its textual claim, the primary focus of its inquiry was the text itself. In the context of these cases, the Court has "never accorded dispositive weight to context shorn of text." Alexander v. Sandoval, 532 U.S. 275, 288 (2001).
216. Insofar as the Court finds that it can "begin ... and ... end [its] search for Congress's intent with the text and structure" of the DRA, id., a lack of legislative history explicitly indicating Congress's intent to abrogate the § 1983 right to enforce Medicaid benefits is unlikely to be relevant.
217. See, e.g., Aaron & Schwartz, supra note 68, at 419.
218. See H.R. REP. No. 109-276, at 389 (2005).
219. Id. at 1221.
220. See Deficit Reduction Act of 2005, Pub. L. No. 109-171, 120 Stat. 3 (2006).
221. 42 U.S.C.A. § 1396u-7(b)(1)(D) (West Supp. 2007).
222. Gonzaga Univ. v. Doe, 536 U.S. 273, 280 (2002).
223. Id. at 288.
224. See supra text accompanying note 145. An exception to this general finding may exist for those elements of coverage that are specifically required under benchmark-equivalent coverage. See 42 U.S.C.A. § 1396u-7 (West Supp. 2007).
225. Gonzaga, 536 U.S. at 283-84 (quoting Cannon v. Univ. of Chi., 441 U.S. 677, 691 (1979)).
226. Id. (quoting Blessing v. Freestone, 520 U.S. 329, 343 (1997)).
227. See CBO ESTIMATE, supra note 47, at 34.
228. 503 U.S. 347 (1992).
229. 42 U.S.C. § 1320a-2 (2000). See generally Brian D. Ledahl, Congress Overriding the Courts: Legislative Changes to the Scope of Section 1983, 29 COLUM. J.L. & Soc. PROBS. 411, 412, 415 (1996) (discussing "how courts should apply the new and confusing statute" and concluding that "courts should not alter their decisions on the basis of the legislative overturning of the Suter decision because nothing was actually overturned by the language of the statute").
230. Unlike federal courts, state trial courts are usually courts of general jurisdiction, with a lower bar for plaintiffs to hurdle in order to obtain review of an action. See Philip A. Talmadge, Understanding the Limits of Power: Judicial Restraint in General Jurisdiction Court Systems, 22 SEATTLE U. L. REV. 695, 709-15 (1999).
231. See CAL. R. CT. 8.490, available at http://www.courtinfo.ca.gov/rules/documents/pdfFiles/title_8.pdf.
232. See Conlan v. Bonta, 125 Cal. Rptr. 2d 788, 803 (Ct. App. 2002) (using a writ of mandamus to compel restructuring of California's Medicaid program to allow retroactive payments for beneficiaries determined to be within the requirements of federal Medicaid law).
233. Conlan v. Shewry, 32 Cal. Rptr. 3d 667, 670 (Ct. App. 2005).
234. See, e.g., Krieger v. Krauskopf, 503 N.Y.S.2d 418 (App. Div. 1986) (utilizing statutorily authorized prerogative writs to compel reimbursement of Medicaid plaintiffs denied funding in violation of federal requirements);
235. see also Martin v. Blum, 448 N.Y.S.2d 873 (App. Div. 1982);
236. Seittelman v. Sabol, 601 N.Y.S.2d 391, 394-95 (Sup. Ct. 1993) (utilizing the same procedure to grant declaratory relief to plaintiffs seeking to invalidate a state regulation on reimbursement for medical services as "irrational and inconsistent with federal law").
237. See Talmadge, supra note 168, at 709-15.
238. See, e.g., Jackson v. Millstone, 801 A.2d 1034, 1041-44 (Md. 2002) (noting the Maryland procedure as it applies to state violations of federal Medicaid requirements).
239. See, e.g., Del. Valley Convalescent Or., Inc. v. Beal, 412 A.2d 514, 515 (Pa. 1980) (rejecting a claim that the fair hearing process can be skipped and suit can be brought directly in state court when plaintiffs make "strictly legal" claims about the illegality of state regulations under federal law).
240. 42 U.S.C. § 1396a(a)(3) (2000).
241. See, e.g., Gould v. Klein, 376 A.2d 196 (N.J. Super. Ct. App. Div. 1977) (rejecting a challenge to a state statute governing reimbursement on judicial review of a fair hearing decision adverse to the beneficiary).
242. See, e.g., Jacobus v. Dep't of PATH, 857 A.2d 785, 789-91 (Vt. 2004) (holding on review of a fair hearing decision that the department's Medicaid regulations violate Medicaid's federal statutory and regulatory comparability requirements).
243. See, e.g., G.B. v. Lackner, 145 Cal. Rptr. 555 (Ct. App. 1978) (holding that the agency's ad hoc denial of a plaintiff's submission for transsexual surgery reimbursement was beyond the scope of its discretion under governing federal and state law).
244. 42 U.S.C. § 1396a(a)(3) (2000).
245. While the use of a state-level ALJ is not strictly mandated, see 42 C.F.R. § 431.240(a)(3) (2007), states generally choose to implement these sorts of requirements through ALJs.
246. See, e.g., KAN. STAT. ANN. 75-3306(h) (1997) (discussing the authority of ALJs in Kansas).
247. But see, e.g., 16 DEL. ADMIN. CODE § 5000 (2007), available at http://regulations.delaware.gov/ AdminCode (indicating that the "hearing officer" is responsible for presiding over the Medicaid fair hearing).
248. 42 C.F.R. § 431.200(b) (2007).
249. Id. § 431.205(d);
250. see also Goldberg v. Kelly, 397 U.S. 254 (1970).
251. STATE MEDICAID MANUAL § 2902.4 (2005), available at http://www.cms.hhs.gov/Manuals/PBM/list.asp (follow "Next" link; then select "The State Medicaid Manual").
252. The Foreword of the State Medicaid Manual indicates that it "is an official medium by which the Health Care Financing Administration (HCFA) issues mandatory, advisory, and optional Medicaid policies and procedures to the Medicaid State agencies." Id. at i.
253. Id. § 2902.4(B), at 2-390.
254. 42 C.F.R. § 431.220 (2007).
255. STATE MEDICAID MANUAL, supra note 184, § 2902.4(A), at 2-389.
256. Id. § 2902.4, at 2-389 ("Issues of fact or judgment include issues of the application of State law or policy to the facts of the individual situation.").
257. 42 C.F.R. § 431.220(b) (2007) (emphasis added).
258. STATE MEDICAID MANUAL, supra note 184, § 2901.3, at 2-387 to -388.
259. Id. at i.
260. 42 C.F.R. § 431.220(a)(2) (2007).
261. Id. § 431.220(b).
262. Id. § 431.222(a), (b).
263. STATE MEDICAID MANUAL supra note 184, § 2902.4(A), at 2-389.
264. Mowbray v. Kozlowski, 724 F. Supp. 404, 417 (W.D. Va. 1989), rev'd on other grounds, 914 F.2d 593 (4th Cir. 1990).
265. Id. at 404.
266. Id. at 418.
267. Id.
268. Id. Even those states that expressly disallow consideration of "law or policy" questions allow the consideration of such claims on judicial review. See generally infra Section IV.B.
269. Mowbray, 724 F. Supp. at 418. The same court repeated the efficiency argument when criticizing Virginia's post-Mowbray formulation of its fair hearing system as still inadequate.
270. See Shifflett v. Kozlowski, 843 F. Supp. 133, 137 (W.D. Va. 1994).
271. See Mowbray, 914 F.2d at 593.
272. See C. Stuart Greer, Note, Expanding the Judicial Power of the Administrative Law Judge To Establish Efficiency and Fairness in Administrative Adjudication, 27 U. RICH. L. REV. 103 (1992).
273. 353 F.3d 1242 (10th Cir. 2004).
274. Id. at 1263.
275. See Benton v. Rhodes, 586 F.2d 1, 3 (6th Cir. 1978).
276. Id. at 2.
277. Id. at 3.
278. Rosen v. Goetz, 410 F.3d 919, 927-28 (6th Cir. 2005).
279. Id. at 927.
280. For a discussion on utilizing fair hearings to challenge the legal validity of state legislative and regulatory actions under the AFDC, see Erika Geetter, Attorney's Fees for § 1983 Claims in Fair Hearings, 55 U. CHI. L. REV. 1267, 1271-72 (1988).
281. See, e.g., Hand v. State Dep't of Human Res., 548 So. 2d 171, 173 (Ala. Civ. App. 1988) ("[W]here an agency prescribes rules and regulations for the orderly accomplishment of its statutory duties, its officials must vigorously comply with those requirements ....").
282. For example, the Alabama Supreme Court has noted that, "[t]his principle prevents agencies from skirting their own regulations by the use of crabbed, ad hoc definitions of regulation terms." Ex parte Wilbanks Health Care Servs., Inc., No. 1060218, 2007 WL 2966817, at *5 (Ala. Oct. 12, 2007).
283. See, e.g., Okla. Dep't of Human Servs., Office of General Counsel, Fair Hearings Information, http://www.okdhs.org/divisionsoffices/ogc/ld/app/ docs/hearappeals.htm (Aug. 1, 2007).
284. ALASKA ADMIN. CODE tit. 7, § 49.170 (2007).
285. See, e.g., KAN. STAT. ANN. § 75-3306(h) (1997) ("The department of social and rehabilitation services shall not have jurisdiction to determine the facial validity of a state or federal statute. The hearings section of the department of social and rehabilitation services shall not have jurisdiction to determine the facial validity of an agency rule and regulation."); 130 MASS. CODE REGS. § 610.082(C)(2) (2006) ("[T]he hearing officer shall render a decision based on the applicable law or regulation as interpreted by the MassHealth agency or the Connector.... The hearing officer cannot rule on the legality of such law or regulation ....").
286. See, e.g., Ussery v. Kan. Dep't of Soc. & Rehab. Servs., 899 P.2d 461 (Kan. 1995) (providing judicial review of a fair hearing challenge to an agency's denial of a subsidy in violation of its own regulations).
287. See, e.g., Americare Props., Inc. v. State Dep't of Soc. & Rehab. Servs., 738 P.2d 450, 453-54 (Kan. 1987) (discussing a Kansas hearing officer's unwillingness to strike down a state statute despite the fact that it "squarely defeat[ed] th[e] purpose" of a controlling federal regulation);
288. Salisbury Nursing & Rehab Ctr., Inc. v. Div. of Admin. Law Appeals, 861 N.E.2d 429, 438 (Mass. 2007) (noting that the Massachusetts Division of Adminstrative Law Appeals does not have jurisdiction to hear "substantive" attacks on regulations governing Medicaid reimbursement rates).
289. See Michele Estrin Gilman, Legal Accountability in an Era of Privatized Welfare, 89 CAL. L. REV. 569, 632-33 (2001).
290. See Brewer v. Schalansky, 102 P.3d 1145, 1154 (Kan. 2004) (reviewing the legality of a state statute governing valuation of resources for consistency with federal law and noting that "Kansas regulations cannot conflict with the federal regulations");
291. Trust Co. of Okla. v. State, 825 P.2d 1295, 1304 (Okla. 1991) (overturning a state policy regarding the treatment of trust fund assets in determining Medicaid eligibility as inconsistent with governing federal law). But see Salisbury, 861 N.E.2d at 429 (holding that the proper mechanism for facial challenges to Medicaid rate reimbursement schemes is the state's Declaratory Judgment Act).
292. 16 DEL. ADMIN. CODE § 5307(2) (2007), http://regulations.delaware.gov/AdminCode/.
293. Id. § 5000 (2007).
294. Id. § 5406.1(1) (2007).
295. N.Y. COMP. CODES R. & REGS. tit. 18, § 358-3.1(f)(4) (2006).
296. N.Y. State Dep't of Health, Other Eligibility Requirements § 375, in MEDICAID REFERENCE GUIDE (2005), http://www.health.state.ny.us/health_care/medicaid/reference/mrg/. The purpose of the Medicaid Reference Guide is "to assist districts in determining Medicaid eligibility for applicants/recipients." Id. at 10.
297. Despite this exception, there do not appear to be any readily available published cases involving judicial review of a pure challenge to a state policy in New York. This is likely because of the wide, established scope of the Article 78 equitable state remedy. See supra notes 172-174 and accompanying text.
298. See, e.g., N.Y. A.P.A. LAW §§ 100-501 (McKinney 2007).
299. See, e.g., Urban v. Meconi, 930 A.2d 860, 864-65 (Del. 2007) (reviewing an appeal from a Medicaid fair hearing and finding that the state's fair hearing decision violated governing federal law).
300. See, e.g., N.Y. COMP. CODES R. & REGS. tit. 18, § 358-5.10 (2006). The federal option is codified at 42 C.F.R. § 431.222 (2007).
301. Frequently, while consolidation is available to increase efficiency, individual beneficiaries have a right to withdraw and have their individual cases adjudged separately. N.Y. COMP. CODES R. & REGS. tit. 18, § 358-5.10(b)(2) (2006).
302. This consolidation remedy, though widely codified, appears to be infrequently exercised. But see Balino v. Dep't of Health & Rehab. Servs., 348 So. 2d 349 (Fla. Dist. Ct. App. 1977).
303. See, e.g., UTAH ADMIN. CODE r.414-301-6(1) (2008).
304. See, e.g., Gustafson v. N.D. Dep't of Human Servs., 712 N.W.2d 599 (N.D. 2006);
305. Sutherland v. N.D. Dep't of Human Servs., 689 N.W.2d 880 (N.D. 2004).
306. See, e.g., Weber Mem. Care Ctr., Inc. v. Utah Dep't of Health, 751 P.2d 831 (Utah 1988) (considering the legality of a duly promulgated state Medicaid regulation).
307. Cf. Shifflett v. Kozlowski, 843 F. Supp. 133 (W.D. Va. 1994) (discussing the changes to the Virginia fair hearing procedures with regard to hearing questions of law or policy in light of the district court's decision five years earlier in Mowbray v. Kozlowski, 724 F. Supp. 404 (W.D. Va. 1989), rev'd on other grounds, 914 F.2d 593 (4th Cir. 1990)).
308. See, e.g., LA. REV. STAT. ANN. §§ 49:963(D), 49:958 (2003) (granting ALJs in Louisiana the authority to rule on the legality of agency policies in matters they are already adjudicating).
309. King v. Sec'y of the La. Dep't of Health & Hosps., 956 So. 2d 666 (La. Ct. App. 2007);
310. Pacente v. Jindal, 751 So. 2d 343 (La. Ct. App. 1999).
311. See generally David H. Williams, Medicaid in Louisiana, in LOUISIANA LEGAL SERVICES AND PRO BONO DESK MANUAL 515, 531-35 (Gillis W. Long Poverty Law Ctr. ed., 2005), available at http://law.loyno.edu/probono/clinic/ manual/LAmanual_medicaid.pdf.
312. See N.J. ADMIN. CODE §§ 10.49-10.8 (2007).
313. See 12 VA. ADMIN. CODE § 30-110-310 (2007).
314. Mark R. Fondacaro, Toward a Synthesis of Law and Social Science: Due Process and Procedural Justice in the Context of National Health Care Reform, 72 DENV. U. L. REV. 303, 339 (1995).
315. Id. at 337-39;
316. see also Goldberg v. Kelly, 397 U.S. 254, 267-71 (1970);
317. Henry J. Friendly, "Some Kind of Hearing," 123 U. PA. L. REV. 1267 (1975).
318. 42 C.F.R. § 431.244(f)(1) (2007).
319. SARAH SOMERS & JANE PERKINS, NAT'L HEALTH LAW PROG., MEDICAID'S AMOUNT, DURATION AND SCOPE REQUIREMENT: CHALLENGING CUTS TO SERVICES FOR ADULTS 10 (2006), available at http://www.nls.org/conf2006/ medicaid's%20amount.pdf.
320. Id.
321. Id.
322. See Williams, supra note 237, at 530-31.
323. See Jim Flanagan, ALJ Decisions-Final or Fallible?, 25 J. NAT'L ASS'N ADMIN. L. JUDGES 191, 191-92 (2005) (noting that in states like South Carolina and Louisiana, ALJs make the final decision, which is then subject to review only by the judiciary, while in states like North Carolina, the ability of agencies to review ALJ decisions is so limited that in practice those decisions carry "de facto finality").
324. See STATE MEDICAID MANUAL, supra note 184, § 2902.4(A) (2005) (noting that a challenge to the "alleged inadequacy of the State program" cannot result in a ruling "in favor of the appellant without a change in agency policy or, in some instances, in State law").
325. See Williams, supra note 237, at 531.
326. See Gilman, supra note 219, at 632-33.
327. REVISED MODEL STATE ADMIN. PROCEDURE ACT art. 5 (Proposed Official Draft 2005).
328. See, e.g., Chippewa County Dep't of Human Servs. v. Bush, 738 N.W.2d 562, 565 (Wis. Ct. App. 2007) (noting that on appeal from a fair hearing decision, interpretations of state statutes and regulations governing Wisconsin's Medicaid program are "independently review[ed]" and that the court is "not bound by an administrative agency's interpretation and application of a statute");
329. Webb v. Fla. Dep't of Children & Family Servs., 939 So. 2d 1182, 1185 (Fla. Dist. Ct. App. 2006); Braddock v. Mo. Dep't of Mental Health, 200 S.W.3d 78, 80 (Mo. Ct. App. 2006);
330. Boruch v. Neb. Dep't of Health & Human Servs., 659 N.W.2d 848, 852 (Neb. Ct. App. 2003) (noting that state appellate courts in Nebraska must "reach[] a conclusion independent of the lower court[]" when reviewing questions of law on appeal from agencies).
331. Mulder v. S.D. Dep't of Soc. Servs., 675 N.W.2d 212, 214 (S.D. 2004) (endorsing the federal Chevron framework directing the court on judicial review to uphold "reasonable" interpretations by the state Medicaid agency);
332. see also Chevron U.S.A., Inc. v. Natural Res. Def. Council, Inc., 467 U.S. 837 (1984).
333. Bezzini v. Dep't of Soc. Servs., 715 A.2d 791, 793 (Conn. App. Ct. 1998) (distinguishing between issues of fact, which get very deferential review, issues of pure law, which get less deferential review, and questions of law "not previously ... subject to judicial scrutiny," which do not get any special deference (quoting Conn. Light & Power Co. v. Tex.-Ohio Power, Inc., 708 A.2d 202, 206 (Conn. 1998)).
334. Harrison v. Comm'r, Dep't of Income Maint., 529 A.2d 188, 193 (Conn. 1987).
335. In at least one case, a state court has rejected an attempt to bind states by federal Medicaid requirements through the fair hearing process by applying § 1983 analysis of the enforceability of the beneficiary's rights. See Keup v. Wis. Dep't of Health & Family Servs., 675 N.W.2d 755 (Wis. 2004).
336. See supra Subsection IV.A.1.
337. See Williams, supra note 237, at 530.
338. See supra note 20 and accompanying text.
339. See supra notes 242-245 and accompanying text.
340. See 42 U.S.C. § 1395ff(b)(1)(A) (2000).