Federalism Affirmed: States Regain Control Over Medicaid and Abortion Policy

In Medina v. Planned Parenthood, the Supreme Court ruled that individual Medicaid patients cannot sue their state when it excludes an abortion provider from the Medicaid program. On the surface, the case turned on a narrow question of statutory interpretation. But in practice, the decision reasserts the principle that federal funding conditions are agreements between governments, not open invitations for private litigation - and it hands more control back to the states in how they manage their Medicaid programs.

Background

Medicaid is a joint federal-state program that helps low-income Americans pay for medical care. The federal government pays most of the bill (about 57%) but lets states run the program - as long as they follow federal rules.

One of those rules says Medicaid patients must be free to choose “any qualified provider.” In plain terms, a state can’t block someone from seeing a doctor or clinic that meets the professional standards the state itself sets. The statute doesn’t define “qualified,” leaving states to set standards relating to health, safety, and medical practice.

South Carolina, which by law does not use public funds for abortion, announced in 2018 that Planned Parenthood could no longer participate in its Medicaid program. The state said it was exercising its authority to decide which providers were qualified.

Planned Parenthood - and one of its patients - sued, saying the state’s decision violated the federal “any qualified provider” rule. Lower courts sided with them, saying that Planned Parenthood could enforce that rule through 42 U.S.C. § 1983.

Federal law (specifically 42 U.S.C. § 1983) allows people to sue state officials who violate their “rights under the Constitution and laws of the United States” - but not every federal law automatically creates an individual right that can be enforced in court.

When Congress uses its spending power - giving money to states on certain conditions - it’s more like a contract rather than a command. The state agrees to follow Congress’s terms in exchange for money. If a state breaks the deal, the usual remedy is that the federal government can cut off funds - not that individuals can sue.

The key question was: did Congress clearly say that Medicaid patients have a personal right to sue if a state limits which providers they can see?

The Majority Opinion - Justice Gorsuch

Justice Gorsuch, writing for the Court, said no. His reasoning centered on one idea: Congress did not clearly create a private right to sue in the statute.

The court began by explaining how funding laws work. When Congress gives money to states, it does so under its spending power - effectively forming a contract. The state accepts the funds and agrees to follow the attached conditions. If the state breaks those conditions, the usual remedy is for the federal government to withhold - not for private citizens to file lawsuits.

The framework has been reaffirmed for decades. The Court has held that individuals can sue under § 1983 only if Congress spoke with a “clear and unambiguous” intent to give them that right. Ambiguity cuts against private enforcement.

Justice Gorsuch found that the Medicaid provision here - § 1396a(a)(23)(A) - does not meet that standard. It tells states what they must do to qualify for federal money; it does not tell individuals that they personally have a right to demand any provider they choose.

He pointed to several clues:

• The statue never uses “rights-creating” language like “individuals shall have the right to…”

• This law allows states to decide what counts as a “qualified” provider and to exclude providers convicted of certain crimes - even deciding which crimes qualify. That kind of discretion is inconsistent with a strict, individual right.

• The statute directs its commands to the Secretary of Health and Human Services, who approves or rejects state plans - another sign that Congress intended administrative, not judicial, enforcement.

In short, the “any qualified provider” rule sets out state duties, not individual entitlements.

Gorsuch also emphasized practical concerns. Allowing private lawsuits over every alleged violation of spending conditions could drain public resources and put courts in the middle of complex policy tradeoffs. Those are decisions for elected representatives, not judges.

Thomas Concurrence

Justice Thomas agreed with the result but took the reasoning even further. He traced § 1983 back to its origins in the Civil Rights Act of 1871, which was designed to enforce constitutional protections after the Civil War, not to turn every federal law into a private cause of action.

Thomas argued that over time, courts have stretched § 1983 far beyond what Congress intended. In his view, by restoring § 1983’s original limits, Medina corrects the drift and will begin to re-anchor the statute in its historical purpose - protecting constitutional rights, not policing every federal funding program.

The Broader Meaning

While the Court’s decision doesn’t directly outlaw anything, it gives states more room to enforce their own standards within Medicaid - including rules that exclude abortion providers. States like South Carolina can now make those policy choices without facing automatic lawsuits from individual Medicaid recipients.

For patients and providers, this means that challenges to state Medicaid rules will have to go through federal oversight - through the Department of Health and Human Services - rather than private litigation.

For Congress, the message is clear: if lawmakers want individuals to be able to sue under a federal funding law, they must say so explicitly. Vague or indirect language won’t suffice.

Conclusion

Medina v. Planned Parenthood ultimately reaffirms a constitutional balance. Congress can set conditions on the money it gives states, but it cannot assume courts will enforce every one of those conditions on behalf of private citizens. States remain co-sovereigns, not mere administrative branches of the federal government.

By holding that Medicaid’s “any qualified provider” clause does not create an individual right to sue, the Court restored a traditional understanding of the spending power - one that leaves enforcement to the political branches and preserves states’ ability to govern sensitive areas like medical licensing and public health policy.

In the long run, Medina is less about Planned Parenthood and more about constitutional structure. It reinforces that in a federal system, Washington sets the terms, but the states keep their sovereignty - and the courts, wisely, stay in their lane.

Read the slip op here