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ADA supports Supreme Court brief, 'profoundly interested'

Basis for challenging Medicaid reimbursement rates at issue

January 16, 2015

By Craig Palmer

Washington – The Supremacy Clause of the U.S. Constitution gives providers "a private right of action" to sue the government to enforce federal Medicaid law in the states, the Association and other health professional associations assert in a friend-of-the-court brief filed with the U.S. Supreme Court. On Jan. 20, the court will hear oral arguments in the case, Armstrong v. Exceptional Child Center, Inc.

Medicaid's "equal access" provision requires that states choosing to accept federal Medicaid funds must set provider reimbursement rates that are "sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area." The issue before the court is this: Whether the federal Supremacy Clause gives Medicaid providers a private right of action to enforce the "equal access" mandate against a state where Congress chose not to create enforceable rights under that statute.

The ADA and six other prominent health professional associations "are profoundly interested in this case because the states' failure to comply with the Medicaid Act's 'equal access' provision has a well-documented, negative impact on patient care," the brief says. In addition to the ADA, the American Medical Association, American Academy of Pediatrics, American Congress of Obstetricians and Gynecologists, American Academy of Family Physicians, American College of Emergency Physicians and California Medical Association signed on to the brief.

Separate friend-of-the-court "amicus" briefs were offered by current and recent members of Congress, former federal Medicaid officials and 19 organizations "committed to serving the needs of low-income persons, including older Americans, individuals with disabilities, children and women of child-bearing age."

The government opposes private action lawsuits by providers "to enjoin state Medicaid reimbursement rates as inconsistent" with the Medicaid equal-access provision. "Section 30 (A) "does not confer on providers any individual right; nor does it entitle them to a certain level of payments that would be enforceable under this court's decision in Gonzaga University v. Doe," said the brief for the United States.

The health care associations' brief, on the other hand, urges the court to focus on "the important role of private actions to enforce the supremacy of federal law including [Medicaid] Section 30(A)'s equal-access mandate and other sections of the Medicaid Act, and urge this court to refrain from deciding issues that are not briefed or presented for decision here."

"This case presents a single question under the Supremacy Clause, and the court should resist the suggestion [in other briefs] to go beyond that question and decide other issues," the professional associations said.

Medicaid beneficiaries and providers have long relied on private lawsuits to remedy states' non-compliance with the equal-access mandate, and reimbursement rates are important to provider participation, the associations said. Private litigation in Connecticut and Oklahoma led to increased dental reimbursement rates and increased access to dental care for children, their brief said.

"The lack of provider participation and resultant unequal access can be deadly," the health professionals' brief argued. "For example, in 2007 a 12-year-old Medicaid recipient named Deamonte Driver died from a brain infection caused by untreated tooth decay." The boy's mother was unable to find a Medicaid-participating dentist to provide preventive care for Deamonte and his brother, the brief said. By the time Deamonte's aching tooth got any attention, bacteria from the abscess had spread to his brain, leading to two operations and more than six weeks of hospital care costing more than $250,000.