PROVIDERS- The Supreme Court Delivers an Unexpected Win for Medicaid Recipients

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[MM Curator Summary]: Yes, Medicaid bennies – you can still sue when providers do wrong stuff. Thanks, SCOTUS!


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— An important accountability measure has been upheld


Andrew J. Twinamatsiko, JD, is an expert in health law and policy. Lawrence O. Gostin, JD, is a leading figure in national and global health law.

The Supreme Court’s decision in Health and Hospital Corporation v. Talevski , holding that beneficiaries of government entitlements can bring civil rights actions to vindicate their rights, is a major victory for millions of Americans who rely on publicly funded healthcare programs.

The justices refused to upend decades of precedent and allowed a nursing home resident’s family to sue an Indiana care home for abusing the resident. Talevski both vindicates the rights of vulnerable citizens and holds officials accountable. It affirms that Medicaid beneficiaries — some of the nation’s most vulnerable and politically powerless members — have a right to dignified care, while empowering them to sue government officials if their rights are not respected. With the recent uptick in state efforts to cut Medicaid, Talevski is a welcome assurance that the courts will remain available as a check on unfair and harmful state policies.

The Details of the Case

The case arose when Gorgi Talevski, a dementia patient at a nursing home owned by Health and Hospital Corporation of Marion County (HHC), suffered multiple abuses. HHC chemically restrained him using strong psychotropic drugs, sent him to a psychiatric facility without consulting his family, and subsequently arbitrarily discharged him. The Indiana State Department of Health failed to remedy the situation.

Talevski’s family brought a private lawsuit under 42 U.S. Code §1983opens in a new tab or window (Section 1983), a law enacted in 1871 that grants individuals the right to sue government officials and others acting “under color of state law” for civil rights violations. Section 1983 does not provide civil rights; it is a means to enforce civil rights that already exist, including Medicaid entitlements. Section 1983’s private right of action is a longstanding and important public accountability mechanism.

Talevski’s ordeal is not surprising. Abuses in nursing homes are commonopens in a new tab or window. Indeed, Congress enacted the Federal Nursing Home Reform Act (FNHRA) in 1987 to address the widespread abuse of residents. FNHRA establishes standards and oversight of nursing homes, including a residents’ bill of rights. FNHRA explicitly states that residents have a right to be free from physical and chemical restraints, and prohibits arbitrary discharge of residents.

Surprisingly, the Supreme Court agreed to hear this case even though there is longstanding precedent for bringing Section 1983 claims and there was unanimity among the circuit courts on the issue. Stakeholders were concerned that a conservative supermajority would use the case to overrule decades of precedent and undermine Medicaid.

Justice Ketanji Brown Jackson, writing for the Court, held that FNHRA unambiguously creates rights that can be vindicated using Section 1983. Jackson noted FNHRA uses “rights-creating language” that explicitly describes freedom from use of unnecessary restraints and the pre-discharge notice requirements as rights to which residents are entitled. What’s more, FNHRA requires nursing homes to respect residents’ rights, which are enforceable by individual residents. The Court rejected HHC’s argument that Congress cannot create rights enforceable under Section 1983 using its spending power, describing HHC’s arguments as “perplexing,” and grounded in “ambiguous historical evidence.”

In his dissent, Justice Clarence Thomas cited federalism concerns that suffused the Court’s reasoning in Dobbs v. Jacksonopens in a new tab or window — ending the right to an abortion — and NFIB v. Sebeliusopens in a new tab or window — striking down the Affordable Care Act’s (ACA) Medicaid expansion requirement — to argue that Spending Clause programs do not grant individual rights. Thus, Thomas would overrule the Court’s established precedents that have governed enforcement of government programs for half a century. Overruling precedent would severely curtail not only Medicaid but also a host of much needed entitlement programs such as the Children’s Health Insurance Program (CHIP), Temporary Assistance for Needy Families (TANF), and the Supplemental Nutrition Assistance Program (SNAP). Curtailing these programs would severely affect marginalized and underserved communities who already bear health burdens at a disproportionately higher rate, and thus exacerbate health disparities.

Health Implications and Takeaways

The Talevski decision is a significant victory for Medicaid beneficiaries as it keeps open the courts’ doors for vindication of federally conferred rights. The Medicaid program is vast, benefiting about 1.7 millionopens in a new tab or window nursing home residents. With at least 15,000 nursing homes across the nation, it is very difficult for the federal and state governments to maintain meaningful oversight to ensure that vulnerable members of society are receiving high quality, dignified care. The only enforcement tool the federal government has for Medicaid violations is to withhold funding, which rarely occurs.

By rebuffing HHC’s “attempts to sow renewed doubts about Section 1983’s” availability to enforce rights under the Spending Clause, the Court preserved an important accountability arrow in the Medicaid quiver. The Court’s rejection of a limited interpretation of the Spending Clause affirms a long-held principle that Medicaid benefits and other entitlements are rights, not privileges that states can take away willy-nilly. Enforcing these rights under Section 1983 gives individuals not only access to the courts but also a suite of remedies, such as injunctions, damages, and attorneys’ fees.

From a health equity standpoint — especially considering the continued worsening of health disparitiesopens in a new tab or window during the COVID-19 pandemic and states moving to purgeopens in a new tab or window their Medicaid rollsopens in a new tab or window — the Talevski decision preserves the important role Medicaid plays in closing health gaps. Since its enactment in 1965, Medicaid has been an indispensable source of access to healthcare for millions of Americansopens in a new tab or window. With the expansion of Medicaid under the ACA, Medicaid’s roleopens in a new tab or window in addressing health disparities cannot be overstated. Various vulnerable groups, comprising a disproportionate number of racial and ethnic minoritiesopens in a new tab or window, rely on Medicaid for their medical needsopens in a new tab or window, such as early screening and preventive services, family planning, inpatient and outpatient hospital care, prescription drugs, and extended institutional care for the elderly.

While the Talevski case centered around only two rights for nursing home residents, the Supreme Court’s ruling broadly encompasses a multitude of rights and welfare programs. In assuring that vulnerable individuals may rely on Section 1983, the Talevski decision will go a long way to preserve people’s rights to timely enrollment, comprehensive coverage, and eligibility determination.

Andrew Twinamatsiko, JD,opens in a new tab or window is an associate director of the Health Policy and the Law Initiative at the O’Neill Institute. Lawrence O. Gostin, JD,opens in a new tab or window is University Professor, Georgetown University’s highest academic rank, where he directs the O’Neill Institute for National & Global Health Law. He is also director of the World Health Organization Collaborating Center on National & Global Health Law. He is the author of the book, Global Health Security: A Blueprint for the Futureopens in a new tab or window.