Obrázky stránek
[blocks in formation]

ties involved to seek such prospective, injunctive relief.” S. Rep. No. 94-1240, at 4.15

This experience demonstrates clearly that Congress and the States both understood the Act to grant health care providers enforceable rights both before and after repeal of the ill-fated waiver requirement. 16 Given this background, it is implausible to conclude that by substituting the requirements

15 See, e. g., H. R. Rep. No. 94-1122, p. 7 (1976) (“[P]roviders can continue, of course, to institute suit for injunctive relief in State or Federal courts, as necessary") (letter from Department of Health, Education and Welfare); State Compliance with Federal Medicaid Requirements: Hearings before the Subcommittee on Health of the Senate Committee on Finance, 94th Cong., 2d Sess., 3 (1976) (providers' recourse, without amendment, includes “injunctive relief against State officials”) (remarks of Assistant Secretary Kurzman); 122 Cong. Rec. 13492 (1976) (“Although the provider can sue the State to enjoin action, they (sic) cannot sue to recover 'lost funds' because of the immunity to suit afforded States by the 11th Amendment”) (remarks of Rep. Rogers).

16 Indeed, federal courts have continued to entertain such challenges since the passage of the Boren Amendment. All the Circuits that have explicitly addressed the issue have concluded that the amendment is enforceable under § 1983 by health care providers. See AMISUB (PSL), Inc. v. Colorado Dept. of Social Services, 879 F. 2d 789, 793 (CA10 1989); West Virginia University Hospitals, Inc. v. Casey, 885 F. 2d 11, 17–22 (CA3 1989), cert. granted, 494 U. S. 1003 (1990); Coos Bay Care Center, 803 F. 2d, at 1061-1063; Nebraska Health Care Assn., Inc. v. Dunning, 778 F. 2d 1291, 1295-1297 (CAS 1985), cert. denied, 479 U. S. 1063 (1987). Other courts have entertained such claims without separately considering whether the providers had a cause of action under $ 1983. See Hoodkroft Convalescent Center, Inc. v. New Hampshire Division of Human Services, 879 F. 2d 968, 972–975 (CA1 1989), cert. denied, 493 U. S. 1020 (1990); Colorado Health Care Assn. v. Colorado Dept. of Social Services, 842 F. 2d 1158, 1165 (CA10 1988); Hillhaven Corp. v. Wisconsin Dept. of Health and Social Services, 733 F. 2d 1224, 1225-1226 (CA7 1984); Alabama Hospital Assn. v. Beasley, 702 F. 2d 955, 955–962 (CA11 1983); Mississippi Hospital Assn., Inc. v. Heckler, 701 F. 2d 511, 517-520 (CA5 1983); Charleston Memorial Hospital v. Conrad, 693 F. 2d 324, 326 (CA4 1982); Washington Health Facilities Assn. v. Washington Dept. of Social and Health Services, 698 F. 2d 964, 965 (CA9 1982).

[blocks in formation]

of “findings” and “assurances,” Congress intended to deprive health care providers of their right to challenge rates under § 1983. Instead, as the legislative history shows, the requirements of “findings” and “assurances” prescribe the respective roles of a State and the Secretary and do not, as petitioners suggest, eliminate a State's obligation to adopt reasonable rates.

Nevertheless, petitioners argue that because the Boren Amendment gives a State flexibility to adopt any rates it finds are reasonable and adequate, the obligation imposed by the amendment is too "vague and amorphous” to be judicially enforceable. We reject this argument. As in Wright, the statute and regulation set out factors which a State must consider in adopting its rates. In addition, the statute requires the State, in making its findings, to judge the reasonableness of its rates against the objective benchmark of an "efficiently and economically operated facilit[y]” providing care in compliance with federal and state standards while at the same time ensuring “reasonable access” to eligible participants. That the amendment gives the States substantial discretion in choosing among reasonable methods of calculating rates may affect the standard under which a court reviews whether the rates comply with the amendment, but it does not render the amendment unenforceable by a court. While

17 For example, when determining methods for calculating rates that are reasonably related to the costs of an efficient hospital, a State must consider: (1) the unique situation (financial and otherwise) of a hospital that serves a disproportionate number of low income patients, (2) the statutory requirements for adequate care in a nursing home, and (3) the special situation of hospitals providing inpatient care when long-term care at a nursing home would be sufficient but is unavailable. 42 U. S. C. $ 1396a(a)(13)(A) (1982 ed., Supp. V). The Boren Amendment provides, if anything, more guidance than the provision at issue in Wright, which vested in the housing authority substantial discretion for setting utility allowances. See Wright v. Roanoke Redevelopment and Housing Authority, 479 U. S. 418, 437 (1987) (O'CONNOR, J., dissenting) (citing 24 CFR $ 965.476(d) (1986)).

[blocks in formation]

there may be a range of reasonable rates, there certainly are some rates outside that range that no State could ever find to be reasonable and adequate under the Act.18 Although some knowledge of the hospital industry might be required to evaluate a State's findings with respect to the reasonableness of its rates, such an inquiry is well within the competence of the Judiciary.

B Petitioners also argue that Congress has foreclosed enforcement of the Medicaid Act under $ 1983. We find little merit in this argument. “We do not lightly conclude that Congress intended to preclude reliance on § 1983 as a remedy' for the deprivation of a federally secured right.” Wright, 479 U. S., at 423-424 (quoting Smith v. Robinson, 468 U. S. 992, 1012 (1984)). The burden is on the State to show “by express provision or other specific evidence from the statute

18 For example, in AMISUB, supra, at 796, the court invalidated the Colorado plan because the State had not made any findings that its rates were “reasonable and adequate” and because the State conceded that the adoption of its “Budget Adjustment Factor” which divided the median cost of care in half had absolutely no relevance to the costs of an efficient hospital. See also Casey, supra, at 22-23 (invalidating Pennsylvania plan because it provided no justification for treating out-of-state hospitals differently than in-state hospitals), cert. granted, 494 U. S. 1003 (1990). If a State errs in finding that its rates are reasonable and adequate, or in supplying assurances to that effect to the Secretary, then a provider is entitled to have the court invalidate the current state plan and order the State to promulgate a new plan that complies with the Act. We note that the Courts of Appeals generally agree that when the State has complied with the procedural requirements imposed by the amendment and regulations, federal court employs a deferential standard of review to evaluate whether the rates comply with the substantive requirements of the amendment. See, e. g., AMISUB, supra, at 795–801; Casey, supra, at 23–24; Dunning, supra, at 1294; Wisconsin Hospital Assn. v. Reivitz, 733 F. 2d 1226, 1232– 1233 (CA7 1984); Mississippi Hospital Assn., supra, at 516. We express no opinion as to which of the cases contains the correct articulation of the appropriate standard of review.

[blocks in formation]

itself that Congress intended to foreclose such private enforcement.” Wright, supra, at 423. Petitioners concede that the Act does not expressly preclude resort to $ 1983. In the absence of such an express provision, we have found private enforcement foreclosed only when the statute itself creates a remedial scheme that is “sufficiently comprehensive ... to demonstrate congressional intent to preclude the remedy of suits under $ 1983.” Middlesex County Sewerage Authority v. National Sea Clammers Assn., 453 U. S. 1, 20 (1981).

On only two occasions have we found a remedial scheme established by Congress sufficient to displace the remedy provided in § 1983. In Sea Clammers, supra, we held that the comprehensive enforcement scheme found in the the Federal Water Pollution Control Act, 33 U. S. C. $ 1251 et seq. which granted the Environmental Protection Agency considerable enforcement power through the use of noncompliance orders, civil suits, and criminal penalties, and which included two citizen-suit provisions -evidenced a congressional intent to foreclose reliance on $ 1983. See 453 U. S., at 13. Similarly in Smith v. Robinson, supra, at 1010-1011, we held that the elaborate administrative scheme set forth in the Education of the Handicapped Act (EHA), 20 U. S. C. $ 1400 et seq., manifested Congress' desire to foreclose private reliance on § 1983 as a remedy. The EHA contained a “carefully tailored administrative and judicial mechanism,” 468 U. S., at 1009, that included local administrative review and culminated in a right to judicial review. Id., at 1011 (citing 20 U. S. C. $$ 1412(4), 1414(a)(5), 1415).

The Medicaid Act contains no comparable provision for private judicial or administrative enforcement. Instead, the Act authorizes the Secretary to withhold approval of plans, 42 U. S. C. $ 1316(a) (1982 ed. and Supp. V), or to curtail federal funds to States whose plans are not in compliance with the Act. 42 U. S. C. $ 1396c (1982 ed.). In addition, the

[blocks in formation]

Act requires States to adopt a procedure for postpayment claims review to “ensure the proper and efficient payment of claims and management of the program.” 42 U. S. C. $ 1396a (a)(37) (1982 ed.). By regulation, the States are required to adopt an appeals procedure by which individual providers may obtain administrative review of reimbursement rates. 42 CFR § 447.253(c) (1989). The Commonwealth of Virginia has adopted a three-tiered administrative scheme within the state Medicaid agency to comply with these regulations. App. 32–43.

This administrative scheme cannot be considered sufficiently comprehensive to demonstrate a congressional intent to withdraw the private remedy of § 1983. In Wright, we concluded that the "generalized powers” of the Department of Housing and Urban Development (HUD) to audit and cut off federal funds were insufficient to foreclose reliance on § 1983 to vindicate federal rights. 479 U. S., at 428. We noted that HUD did not exercise its auditing power frequently, and the statute did not require, nor did HUD provide, any mechanism for individuals to bring problems to the attention of HUD. Ibid.; see also Rosado, 397 U. S., at 420–423. Such a conclusion is even more appropriate in the context of the Medicaid Act, since as explained above, see supra, at 515-518, a primary purpose of the Boren Amendment was to reduce the role of the Secretary in determining methods for calculating payment rates. It follows that the Secretary's limited oversight is insufficient to demonstrate an intent to foreclose relief altogether in the courts under § 1983.19

19 Indeed, this conclusion is even more apt given that Congress believed that a private judicial remedy existed before the passage of the Boren Amendment, see supra, at 516-518, when the administrative oversight scheme was more elaborate than it is today.

For the same reasons, we reject the argument that the availability of an action against the Secretary under the APA forecloses § 1983 as a remedy. Putting aside the question whether an APA remedy is available, see n. 12, supra, there is absolutely no indication that Congress intended such an ac

« PředchozíPokračovat »