Medina

Majority — Gorsuch

Joined by: Roberts, Thomas, Alito, Kavanaugh, Barrett

The majority held that for a federal spending-program statute to create rights enforceable by private individuals under § 1983, Congress must use language that "clearly and unambiguously" creates individual rights — not just language that benefits a group or imposes duties on states. The Court reasoned that Medicaid, like all spending-power legislation, works like a contract between the federal government and states, and states must have unmistakable notice that accepting federal funds also means accepting the risk of private lawsuits. Comparing the provision to the Federal Nursing Home Reform Act (FNHRA) provisions upheld in the 2023 Talevski case — which explicitly used words like "right to be free from" restraints and appeared under a heading called "requirements relating to residents' rights" — the majority found the Medicaid free-choice provision uses no such clear rights-creating language. The Court also noted that the provision appears as one of 87 plan requirements directed at the Secretary of Health and Human Services, that the law requires only "substantial" compliance (suggesting a focus on aggregate state obligations rather than individual rights), and that allowing this provision to create enforceable rights would likely cause many similar Medicaid provisions to do the same — making rights the rule rather than the rare exception. The majority added that other enforcement tools exist, including federal funding cutoffs and state administrative processes, and that if those are insufficient, Congress — not courts — is the proper body to create new remedies.

Dissent reasoning

The dissent argued that the free-choice-of-provider provision does satisfy the unambiguous-conferral test established in Gonzaga and reaffirmed in Talevski, and that the majority distorts that test by treating the FNHRA provisions from Talevski as the only acceptable model for rights-creating language. Justice Jackson wrote that the provision's text is plainly "individual-centric" — it states that "any individual eligible for medical assistance may obtain such assistance from any qualified provider" — and that Congress reinforced its intent by using the mandatory word "must" and by titling the provision "FREE CHOICE by individuals eligible for medical assistance" in the original session law, language that echoes rights-protecting phrases like the First Amendment's "free exercise" of religion. The dissent also pointed to the provision's legislative history, noting Congress enacted it specifically to stop states from steering Medicaid patients to preferred providers, and that it was modeled on a Medicare provision that had long been understood to guarantee free choice of provider. The dissent further argued that the majority's "parade of horribles" — the fear that recognizing this right would flood courts with § 1983 suits over other Medicaid provisions — is contradicted by decades of lower-court practice, in which courts recognized rights in only a tiny handful of the Act's nearly 90 state-plan requirements. Finally, the dissent contended that by the time South Carolina acted in 2018, the state had ample notice it could face a § 1983 suit, given longstanding federal government positions, prior Supreme Court language in O'Bannon v. Town Court Nursing Center describing the provision as giving recipients "the right to choose" their providers, and near-unanimous circuit court agreement that the provision was enforceable.