Opinion ID: 810673
Heading Depth: 2
Heading Rank: 1

Heading: The Medicaid Act Claim

Text: 1. Is There a Private Right of Action Enforceable Under § 1983? Section 1983 creates a federal remedy against anyone who, under color of state law, deprives “any citizen of the United States . . . of any rights, privileges, or immunities secured by the Constitution and laws.” 42 U.S.C. § 1983. In Maine v. Thiboutot, 448 U.S. 1 (1980), the Supreme Court held that § 1983 “means what it says,” id. at 4, and “authorizes suits to enforce individual rights under federal statutes as well as the Constitution,” City No. 11-2464 13 of Rancho Palos Verdes, Cal. v. Abrams, 544 U.S. 113, 119 (2005). But “it is rights, not the broader or vaguer ‘benefits’ or ‘interests,’ that may be enforced under the authority of that section.” Gonzaga Univ., 536 U.S. at 283. Three factors help determine whether a federal statute creates private rights enforceable under § 1983: (1) “Congress must have intended that the provision in question benefit the plaintiff”; (2) the asserted right must not be “so vague and amorphous that its enforcement would strain judicial competence”; and (3) “the provision giving rise to the asserted right must be couched in mandatory, rather than precatory, terms.” Blessing v. Freestone, 520 U.S. 329, 340-41(1997) (internal quotation marks omitted). These factors are meant to set the bar high; nothing “short of an unambiguously conferred right [will] support a cause of action brought under § 1983.” Gonzaga Univ., 536 U.S. at 283. “[W]here the text and structure of a statute provide no indication that Congress intends to create new individual rights, there is no basis for a private suit, whether under § 1983 or under an implied right of action.” Id. at 286. In the context of legislation adopted under the spending power,5 this rigorous approach reflects concerns about federalism and reinforces the principle that Congress must clearly express its “intent to 5 See U.S. C ONST . art. I, § 8, cl. 1 (“The Congress shall have Power To lay and collect Taxes . . . to pay the Debts and provide for the . . . general Welfare of the United States . . . .”). 14 No. 11-2464 impose conditions on the grant of federal funds so that the States can knowingly decide whether or not to accept those funds.” Pennhurst State Sch. & Hosp. v. Halderman, 451 U.S. 1, 24 (1981); see also Arlington Cent. Sch. Dist. Bd. of Educ. v. Murphy, 548 U.S. 291, 296 (2006) (requiring that spending statutes provide “clear notice” of state obligations). Pennhurst analogized cooperative Spending Clause legislation to a contract between the federal government and willing states: “[L]egislation enacted pursuant to the spending power is much in the nature of a contract: in return for federal funds, the States agree to comply with federally imposed conditions.” 451 U.S. at 17. As such, the legitimacy of spending-power legislation “rests on whether the State voluntarily and knowingly accepts the terms of the ‘contract.’ ” Id. There cannot be knowing acceptance “if a State is unaware of the conditions or is unable to ascertain what is expected of it.” Id.; see also Arlington Cent. Sch. Dist., 548 U.S. at 296. The Supreme Court has repeatedly reaffirmed this understanding, most recently in National Federation of Independent Business v. Sebelius, 132 S. Ct. at 2601-02. Accordingly, “where a statute by its terms grants no private rights to any identifiable class,” Gonzaga Univ., 536 U.S. at 284 (internal quotation marks omitted), it cannot be construed to confer an individual right enforceable under § 1983, id. at 284-85. Instead, to create judicially enforceable private rights, the statute “ ‘must be phrased in terms of the persons benefited,’ ” with “ ‘an unmistakable focus on the benefited class.’ ” Id. (quoting Cannon v. Univ. of Chi., 441 U.S. 677, 691, 692 n.13 (1979)). It must “confer[] entitlements ‘sufficiently specific No. 11-2464 15 and definite to qualify as enforceable rights.’ ” Id. at 280 (quoting Wright v. Roanoke Redev. & Hous. Auth., 479 U.S. 418, 432 (1987)). In other words, the statute must contain “rights-creating language” that unambiguously creates an “ ‘individual entitlement.’ ” Id. at 287 (quoting Blessing, 520 U.S. at 343). “Once a plaintiff demonstrates that a statute confers an individual right, the right is presumptively enforceable by § 1983.” Id. at 284. The defendant may defeat this presumption by demonstrating “that Congress shut the door to private enforcement either expressly, through specific evidence from the statute itself, or impliedly, by creating a comprehensive enforcement scheme that is incompatible with individual enforcement under § 1983.” Id. at 284 n.4 (internal quotation marks and citations omitted); see also Wilder, 496 U.S. at 520-21; Middlesex Cnty. Sewerage Auth. v. Nat’l Sea Clammers Ass’n, 453 U.S. 1, 20 (1981) (holding that there is no enforceable private right where the statute itself creates a remedial scheme that is “sufficiently comprehensive . . . to demonstrate congressional intent to preclude the remedy of suits under § 1983”). Applying these principles here, we agree with the district court that the free-choice-of-provider statute unambiguously gives Medicaid-eligible patients an individual right. Section 1396a(a)(23) mandates that all state Medicaid plans provide that “any individual eligible for medical assistance . . . may obtain such assistance from any institution, agency, community pharmacy, or person, qualified to perform the service or services required.” Medicaid patients are the obvious 16 No. 11-2464 intended beneficiaries of the statute; it states that any Medicaid-eligible person may obtain medical assistance from any institution, agency, or person qualified to perform that service. In other words, Medicaid patients have the right to receive care from the qualified provider of their choice. This language does not simply set an aggregate plan requirement, but instead establishes a personal right to which all Medicaid patients are entitled. Gonzaga Univ., 536 U.S. at 288 (contrasting a statute with an “aggregate” focus with one that is focused on the needs of an identified class of persons). Section 1396a(a)(23) uses “individually focused terminology,” id. at 287, unmistakably “ ‘phrased in terms of the persons benefitted,’ ” id. at 284 (quoting Cannon, 441 U.S. at 692 n.13). Second, the right is administrable and falls comfortably within the judiciary’s core interpretive competence. Planned Parenthood argues that a state infringes the freechoice-of-provider right when it excludes a provider from its Medicaid program for a reason other than the provider’s fitness to render the medical services required. Whether this is the proper interpretation of § 1396a(a)(23) is a legal question fully capable of judicial resolution. Finally, § 1396a(a)(23) is plainly couched in mandatory terms. It says that all states “must provide” in their Medicaid plans that beneficiaries may obtain medical care from any provider qualified to perform the service. In sum, the free-choice-of-provider statute explicitly refers to a specific class of people—Medicaid-eligible No. 11-2464 17 patients—and confers on them an individual entitlement—the right to receive reimbursable medical services from any qualified provider. We agree with the district court that § 1396a(a)(23) unambiguously creates private rights “presumptively enforceable by § 1983.” Gonzaga Univ., 536 U.S. at 284. Nothing in the Medicaid Act suggests, explicitly or implicitly, that “Congress specifically foreclosed a remedy under § 1983.” Id. at 284 n.4 (internal quotation marks omitted). Indiana points to the Medicaid Act’s general administrative scheme—more specifically, to the HHS Secretary’s authority to review state plans for compliance and withhold or curtail Medicaid funds as a means of bringing noncompliant states into line. See 42 U.S.C. §§ 1316(a), 1396c; 42 C.F.R. § 430.12(c). The State suggests that this feature of the administrative scheme implies that Congress foreclosed private enforcement of § 1396a(a)(23). But the Secretary’s power to shut off all or part of a state’s funding is not a “comprehensive enforcement scheme,” see Gonzaga Univ., 536 U.S. at 284 n.4, nor does the administrative-approval process for plan amendments provide an avenue for beneficiaries to vindicate their free-choice-of-provider rights, cf. Middlesex Cnty. Sewerage Auth., 453 U.S. at 20 (explaining that where a federal statute provides “its own comprehensive enforcement scheme, the requirements of that enforcement procedure may not be bypassed by bringing suit directly under § 1983”). It would be a different matter if Congress had provided an administrative remedy for individual patients. “The 18 No. 11-2464 provision of an express, private means of redress in the statute itself is ordinarily an indication that Congress did not intend to leave open a more expansive remedy under § 1983.” Rancho Palos Verdes, 544 U.S. at 121. But Congress did not provide a means of private redress here. And private enforcement of § 1396a(a)(23) in suits under § 1983 in no way interferes with the Secretary’s prerogative to enforce compliance using her administrative authority. Indeed, addressing a different subsection of § 1396a(a), the Supreme Court has held that the Medicaid Act’s “administrative scheme cannot be considered sufficiently comprehensive to demonstrate a congressional intent to withdraw the private remedy of § 1983.” Wilder, 496 U.S. at 522. Wilder held that the Boren Amendment, which established a standard for Medicaid reimbursement of hospitals, nursing homes, and intermediate-care facilities, is enforceable under § 1983. Id. (holding that 42 U.S.C. § 1396a(a)(13)(A) is enforceable in a suit under § 1983). Our conclusion finds support in decisions from other circuits. In Harris v. Olszewski, 442 F.3d 456, 459 (6th Cir. 2006), the Sixth Circuit squarely addressed this issue and held that § 1396a(a)(23) uses the kind of rightscreating, mandatory language required to create individual rights enforceable under § 1983. The court went on to note that although there may be legitimate debates about the medical care covered by or exempted from the freedom-of- choice provision, the mandate itself does not contain the kind of vagueness that would push the limits of judicial enforcement. Whether a state No. 11-2464 19 plan provides an individual with the choice specified in the provision is likely to be readily apparent . . . . Id. at 462. Finally, the court observed that the Medicaid Act does not “explicitly or implicitly foreclose the private enforcement of this statute through § 1983 actions.” Id. More particularly, the Act “does not provide other methods for private enforcement.” Id. In short, applying the Gonzaga University test, the Sixth Circuit concluded that § 1396a(a)(23) “creates enforceable rights that a Medicaid beneficiary may vindicate through § 1983.“ 6 Id. at 461. Other circuits have reached the same conclusion in cases involving individual suits for violation of § 1396a(a)(8), which requires that state Medicaid plans “provide that all individuals wishing to make application for medical assistance under the plan shall have opportunity to do so, and that such assistance shall be furnished with reasonable promptness to all eligible individuals.” 42 U.S.C. § 1396a(a)(8); see Doe v. Kidd, 501 F.3d 348, 355-57 (4th Cir. 2007); Sabree ex rel. Sabree v. Richman, 367 F.3d 180, 189-93 (3d Cir. 2004); Bryson v. Shumway, 308 F.3d 79, 88-89 (1st Cir. 2002); Doe ex rel. 6 The Eleventh Circuit agrees, albeit in a case decided prior to Gonzaga University. See Silver v. Baggiano, 804 F.2d 1211, 1218 (11th Cir. 1986), abrogated on other grounds by Lapides v. Bd. of Regents of Univ. Sys. of Ga., 523 U.S. 613 (2002) (holding that “Medicaid recipients do have enforceable rights under § 1396a(a)(23)”). 20 No. 11-2464 Doe v. Chiles, 136 F.3d 709, 715-19 (11th Cir. 1998).7 And we have recently followed the lead of our sister circuits in finding an enforceable individual right in yet another provision of § 1396a(a)—subsection (10), which requires that state Medicaid plans “must . . . provide . . . for making medical assistance available . . . to all [eligible] individuals.” See Bontrager v. Ind. Family & Soc. Servs. Admin., No. 11-3710, 2012 WL 4372524,  (7th Cir. Sept. 26, 2012) (citing Watson v. Weeks, 436 F.3d 1152, 1159-61 (9th Cir. 2006); Sabree, 367 F.3d at 189-92; South Dakota ex rel. Dickson v. Hood, 391 F.3d 581 604-06 (5th Cir. 2004)). The free-choice-of-provider provision uses language far more concrete and individually focused than either subsection (8) or (10) of § 1396a(a). Indiana’s position is hard to reconcile with Wilder and a fair amount of precedent from this and other circuits.8 Against this authority, Indiana insists that legislation adopted under Congress’s spending power cannot create individual rights enforceable under § 1983 because its legal force stems from a state’s acceptance of federal 7 We have assumed without deciding that § 1396a(a)(8) creates an enforceable individual right. See Bertrand ex rel. Bertrand v. Maram, 495 F.3d 452, 457 (7th Cir. 2007) (“This circuit has itself assumed after Gonzaga University that § 1396a(a)(8) may be enforced via § 1983.”). 8 One district-court decision supports Indiana’s argument. See M.A.C. v. Betit, 284 F. Supp. 2d 1298, 1307 (D. Utah 2003). As the Sixth Circuit has observed, however, that opinion offers virtually no analysis of the issue. See Harris v. Olszewski, 442 F.3d 456, 463 (6th Cir. 2006). No. 11-2464 21 funding rather than from the law itself. This categorical argument cannot be correct; if it were, then the elaborate doctrine worked out in Gonzaga University and its predecessors was completely unnecessary. Not too long ago we made this very point, observing that the Supreme Court’s recent statutory-right-of-action cases “do not stand for a broad rule that spending power statutes can never be enforced by private actions” under § 1983. Ind. Prot. & Advocacy Servs. v. Ind. Family & Soc. Servs. Admin., 603 F.3d 365, 378 (7th Cir. 2010) (en banc). Taking a slightly different tack, Indiana argues that the free-choice-of-provider statute does not create privately enforceable rights because the conditions listed in § 1396a(a) are simply criteria for federal reimbursement, not requirements that must be met by participating states. In other words, noncompliance with the conditions listed in § 1396a(a) puts the State at risk of losing its federal Medicaid funding but does not constitute a violation of federal law.9 To be sure, non- 9 In a related argument, Indiana maintains that federal statutes specifying the requirements of state Medicaid plans cannot impose legal obligations on state officials. Congress specifically foreclosed this argument when it enacted 42 U.S.C. § 1320a-2, which states that a provision of the Medicaid Act “is not to be deemed unenforceable because of its inclusion in a section of this chapter requiring a State plan or specifying the required contents of a State plan.” See Harris v. James, 127 F.3d 993, 1003 (11th Cir. 1997) (explaining that § 1320a-2 establishes that “the mere fact that an obligation is couched in (continued...) 22 No. 11-2464 compliance with the requirements of § 1396a(a) may serve as a basis for the Secretary’s disapproval of a state’s Medicaid plan and withholding of Medicaid funds, but that does not mean that § 1396a(a) functions only as a condition precedent to the federal government’s obligation to keep its end of the Medicaid bargain. Federal statutes enacted pursuant to the spending power do not create federal rights or obligations of their own force, but “once a state elects to participate [in Medicaid], it must abide by all federal requirements and standards as set forth in the Act.” Collins, 349 F.3d at 374 (citing Wilder, 496 U.S. at 502); see also Alexander, 469 U.S. at 289 n.1. As we have explained, the contract model for interpreting Spending Clause legislation has important implications for the relationship between the federal government and the states, see Nat’l Fed’n of Indep. Bus., 132 S. Ct. at 2601-03; Pennhurst, 451 U.S. at 17, but it does not follow that Spending Clause legislation can never create judicially enforceable individual rights. Finally, Indiana argues that allowing private enforcement of the free-choice-of-provider requirement would conflict with O’Bannon v. Town Court Nursing Center, 447 U.S. 773 (1980), and Kelly Kare, Ltd. v. O’Rourke, 930 9 (...continued) a requirement that the State file a plan is not itself sufficient grounds for finding the obligation unenforceable under § 1983 ”). No. 11-2464 23 F.2d 170 (2d Cir. 1991). We disagree. In O’Bannon the Supreme Court held that a state need not provide a pretermination hearing to Medicaid beneficiaries when state officials terminate a medical provider (in that case, a nursing home) as unfit to participate in Medicaid. 447 U.S. at 785. The Court explained its holding as follows: [T]he Medicaid provisions relied upon by the Court of Appeals do not confer a right to continued residence in a home of one’s choice. Title 42 U.S.C. § 1396a(a)(23) . . . gives [Medicaid] recipients the right to choose among a range of qualified providers, without government interference. By implication, it also confers an absolute right to be free from gov- ernment interference with the choice to remain in a home that continues to be qualified. But it clearly does not confer a right on a recipient to enter an unqualified home and demand a hearing to certify it, nor does it confer a right on a recipient to continue to receive benefits for care in a home that has been decertified. Id. Similarly, in Kelly Kare the free-choice-of-provider statute was raised in the context of a due-process claim. A home-healthcare provider and its patients alleged that they were deprived of due process when the State cancelled the provider’s contract based on allegations of unfitness without providing a pre-termination hearing. Relying on O’Bannon, the Second Circuit rejected the claim: 24 No. 11-2464 We read O’Bannon as holding that a Medicaid recipient’s freedom of choice rights are necessarily dependent on a provider’s ability to render services. No cognizable property interest can arise in the Medicaid recipient unless the provider is both qualified and participating in the Medicaid program. Kelly Kare, 930 F.2d at 178. Neither O’Bannon nor Kelly Kare supports Indiana’s argument. This is not a due-process case. Planned Parenthood and its patients are not suing for violation of their procedural rights; they are making a substantive claim that Indiana’s defunding law violates § 1396a(a)(23). As the Supreme Court explained in O’Bannon, § 1396a(a)(23) “gives [Medicaid] recipients the right to choose among a range of qualified providers.” 447 U.S. at 785. This language reinforces rather than undermines our conclusion that § 1396a(a)(23) confers individual rights enforceable under § 1983. 2. Does the Defunding Law Violate § 1396a(a)(1)? Indiana argues that even if § 1396a(a)(23) confers an individual right, the states may establish provider qualifications that effectively limit that right. It is true that Medicaid regulations permit the states to establish “reasonable standards relating to the qualifications of providers.” 42 C.F.R. § 431.51(c)(2). But Indiana claims plenary authority to exclude Medicaid providers for any reason, as long as it furthers a legitimate state interest—here, the State’s interest in avoiding indirect No. 11-2464 25 subsidization of abortion. This sweeping claim conflicts with the unambiguous language of § 1396a(a)(23) and finds no support in related Medicaid statutes and regulations. To repeat, § 1396a(a)(23) requires that state Medicaid plans must provide that “any individual eligible for medical assistance . . . may obtain such assistance from any institution, agency, community pharmacy, or person, qualified to perform the service or services required.” 42 U.S.C. § 1396a(a)(23) (emphases added). The Act does not define what it means for a provider to be “qualified,” and the term is not self-defining. See B LACK’S L AW D ICTIONARY 1360 (9th ed. 2009) (defining “qualified” as “[p]ossessing the necessary qualifications; capable or competent”). Medicaid regulations provide that the states may establish “reasonable standards relating to the qualifications of providers.” 42 C.F.R. § 431.51(c)(2). This authority, however, does not suggest that states are free to ascribe any meaning to the statutory term “qualified”—including a meaning “ ‘entirely strange to those familiar with its ordinary usage.’ ” United States v. Little Lake Misere Land Co., 412 U.S. 580, 596 (1973) (quoting De Sylva v. Ballentine, 351 U.S. 570, 581 (1956)). As the limiting term “reasonable” in the regulation suggests, a state’s authority to determine provider qualifications must be keyed to the “permissible variations in the ordinary concept” of what it means to be “qualified” in this particular context. De Sylva, 351 U.S. at 581. Read in context, the term “qualified” as used in § 1396a(a)(23) unambiguously relates to a provider’s 26 No. 11-2464 fitness to perform the medical services the patient requires. The statute provides that Medicaid beneficiaries “may obtain [medical] assistance from any institution, agency . . . or person[] qualified to perform the service or services required.” To be “qualified” in the relevant sense is to be capable of performing the needed medical services in a professionally competent, safe, legal, and ethical manner. Planned Parenthood’s clinics are “qualified” in the sense meant by § 1396a(a)(23). Indiana argues that the term is more elastic and includes the authority to establish provider-eligibility criteria based on any legitimate state interest. That interpretation of § 1396a(a)(23) would lead to strange results. If the states are free to set any qualifications they want—no matter how unrelated to the provider’s fitness to treat Medicaid patients—then the free-choice-of-provider requirement could be easily undermined by simply labeling any exclusionary rule as a “qualification.” This would open a significant loophole for restricting patient choice, contradicting the broad access to medical care that § 1396a(a)(23) is meant to preserve. Indiana attempts to articulate a limiting principle, but its effort is unpersuasive. It suggests that “a [s]tate may not use a qualification to target patient choice as such—for example by eliminating all choice in the market—but it may reduce patient choice incident to a qualification targeting some legitimate government objective, such as the desire not to subsidize abortion even indirectly.” This argument inverts what the statute says. Section 1396a(a)(23) does not simply bar the states No. 11-2464 27 from ending all choice of providers, it guarantees to every Medicaid beneficiary the right to choose any qualified provider. Looking for support elsewhere in the Medicaid Act, Indiana focuses on § 1396a(p)(1), which elaborates on the states’ authority to exclude Medicaid providers: In addition to any other authority, a State may exclude any individual or entity for purposes of participating under the State plan under this subchapter for any reason for which the Secretary could exclude the individual or entity from participation in a program under subchapter XVIII of this chapter under section 1320a-7, 1320a-7a, or 1395cc(b)(2) of this title. 42 U.S.C. § 1396a(p)(1). The cross-referenced sections of the Medicaid Act—§§ 1320a-7, 1320a-7a, and 1395cc(b)(2)— pertain to mandatory or permissive exclusions of providers for various forms of malfeasance such as fraud, drug crimes, and failure to disclose necessary information to regulators. Indiana emphasizes the phrase “[i]n addition to any other authority” and suggests that this language implies a plenary power reserved to the states to exclude Medicaid providers as they see fit. This reads the phrase for more than it’s worth. “[I]n addition to any other authority” signals only that what follows is a nonexclusive list of specific grounds upon which states may bar providers from participating in Medicaid. It does not imply that the states have an unlimited authority to exclude providers for any reason whatsoever. 28 No. 11-2464 To bolster its implied-authority argument, Indiana relies on a Senate Finance Committee Report explaining that § 1396a(p)(1) “is not intended to preclude a State from establishing, under State law, any other bases for excluding individuals or entities from its Medicaid program.” S. R EP. N O . 100-109, at 20 (1987) (emphasis added), reprinted in 1987 U.S.C.C.A.N. 682, 700. The Senate Report is not useful here; it suggests only that § 1396a(p)(1) does not have preemptive effect. The Senate Report does not—indeed, it cannot—alter the plain meaning of “qualified” as that term is used in § 1396a(a)(23). Indiana also points to 42 U.S.C. § 1320a-7(b)(14), which allows states to exclude providers who are in default on their student-loan payments, and from this provision makes another argument by implication: If the states may refuse to subsidize student-loan delinquents with Medicaid dollars, then they must have the authority to “avoid indirect financing” of any “non-Medicaid” conduct. But like § 1396a(p)(1), this statute merely stipulates a particular ground for excluding a Medicaid provider; it does not imply that the states may establish any rule of exclusion and declare it a provider “qualification” for purposes of § 1396a(a)(23). That would make the freechoice-of-provider requirement a nullity. Finally, the cases Indiana cites do not support its position. In First Medical Health Plan, Inc. v. Vega-Ramos, 479 F.3d 46 (1st Cir. 2007), for instance, the First Circuit simply recognized the point we have just made—that states may exclude providers from participating in Medicaid for reasons not listed in § 1396a(p)(1). VegaNo. 11-2464 29 Ramos, moreover, involved a conflict-of-interest rule applicable only in Puerto Rico; the First Circuit had no reason to consider the effect of the free-choice-ofprovider requirement, which does not apply to Puerto Rico’s Medicaid program. See 42 U.S.C. § 1396a(a)(23)(B). The court’s opinion thus cannot be understood to suggest that states may override the free-choice-of-provider requirement by creating “qualifications” wholly unrelated to the competent delivery of medical services. Nor does Guzman v. Shewry, 552 F.3d 941 (9th Cir. 2009), help Indiana’s case. There, a provider was suspended from California’s Medicaid program based on a pending criminal investigation. He claimed that federal law occupies the entire field of regulation pertaining to Medicaid and therefore preempted the state’s disciplinary measure. The Ninth Circuit rejected this argument, relying in part on 42 U.S.C. § 1320a-7(b)(5), which provides that the states may suspend or exclude providers from participating in Medicaid “for reasons bearing on the individual’s or entity’s professional competence, professional performance, or financial integrity.” The court remarked that this provision presupposes state regulatory authority over provider qualifications. Guzman, 552 F.3d at 949. No one disputes that the states retain considerable authority to establish licensing standards and other related practice qualifications for providers—this residual power is inherent in the cooperative-federalism model of the Medicaid program and expressly recognized in the Medicaid regulations. See 42 C.F.R. § 431.51(c)(2) 30 No. 11-2464 (providing that states may establish “reasonable standards relating to the qualifications of providers”). This case raises a question about the limits of that authority. Guzman, which involved state action falling within the core of the state’s residual authority, does not support Indiana’s argument. Before concluding our discussion of the Medicaid Act claim, a few words about agency deference, which the district court applied and the parties briefed on appeal. As an additional reason to affirm the district court’s decision, Planned Parenthood argues, and the United States agrees, that we should defer to the CMS Administrator’s interpretation of § 1396a(a)(23) under Chevron. See Chevron, U. S. A., Inc. v. Natural Res. Def. Council, Inc., 467 U.S. 837 (1984). But Chevron deference is triggered only when a statute is ambiguous. Id. at 842-43 (“If the intent of Congress is clear, that is the end of the matter; for the court, as well as the agency, must give effect to the unambiguously expressed intent of Congress.”). As we have explained, the term “qualified” as used in § 1396a(a)(23) unambiguously refers to the provider’s fitness to render the medical services required. See generally Carcieri v. Salazar, 555 U.S. 379, 391 (2009) (noting that statutory text susceptible to alternative meanings is not ambiguous when its meaning is clear in light of the statutory context). In the absence of ambiguity, Chevron deference does not come into play. Because Indiana’s defunding law excludes a class of providers from Medicaid for reasons unrelated to provider qualifications, we agree with the district court that Planned Parenthood is likely to succeed on its No. 11-2464 31 claim that Indiana’s defunding law violates § 1396a(a)(23). This brings us to the district court’s evaluation of the balance of harms and the effect of preliminary injunctive relief on the public interest. 3. Balance of Harms and the Public Interest The court below held that the loss of Medicaid funding would cause Planned Parenthood immediate irreparable harm. Indiana does not seriously challenge this conclusion. Planned Parenthood would have to lay off dozens of workers, close multiple clinics, and stop serving a significant number of its patients. Planned Parenthood of Ind., 794 F. Supp. 2d at 912. Absent a preliminary injunction, its Medicaid patients would lose their provider of choice for the duration of the litigation. Id. at 912-13. These harms are entitled to significant weight given Planned Parenthood’s strong likelihood of success on the merits of its Medicaid Act claim. In addition, the district court noted that “[t]he federal government has threatened partial or total withholding of federal Medicaid dollars to the State of Indiana, which could total well over $5 billion dollars annually and affect nearly 1 million Hoosiers.” Id. at 913. The judge saw “a high-stakes political impasse” looming, with the well-being of Indiana’s Medicaid patients hanging in the balance: “[I]f dogma trumps pragmatism and neither side budges, Indiana’s most vulnerable citizens could end up paying the price as the collateral damage of a partisan battle.” Id. This helped tip the scales in favor of a preliminary injunction. 32 No. 11-2464 Without endorsing the political commentary, we see no reason to disturb the district court’s assessment of the balance of harms and the public interest. Indiana maintains that any harm to Planned Parenthood’s Medicaid patients is superficial because they have many other qualified Medicaid providers to choose from in every part of the state. This argument misses the mark. That a range of qualified providers remains available is beside the point. Section 1396a(a)(23) gives Medicaid patients the right to receive medical assistance from the provider of their choice without state interference, save on matters of provider qualifications. Indiana also argues that the district court’s preliminary injunction “completely undermines” the public’s interest in the established administrative process. We cannot see how. Indiana’s appeal of the CMS Administrator’s decision has proceeded in the ordinary course. It is true that the federal government’s position as an amicus curiae in this litigation makes it unlikely that the HHS Secretary will overrule the CMS Administrator’s decision and approve Indiana’s request to amend its Medicaid plan. But that has no real effect on the balance of harms. And if the Secretary approves the plan amendment, Indiana may ask for relief from the preliminary injunction. In the end, our review of this aspect of the district court’s decision is deferential. The judge appropriately weighed the relative harm to the parties and the public interest and reasonably concluded that it warranted No. 11-2464 33 preliminary injunctive relief on the Medicaid Act claim. That decision was not an abuse of discretion.