Court Opinion

ID: 6321219
Source: CourtListenerOpinion
Date Created: 2022-03-08 20:00:58.226569+00
Date Added: 2024-06-11T08:04:13.199197
License: Public Domain

PUBLISHED

                           UNITED STATES COURT OF APPEALS
                               FOR THE FOURTH CIRCUIT

                                         No. 21-1043

PLANNED PARENTHOOD SOUTH ATLANTIC; JULIE EDWARDS, on her
behalf and on behalf of all others similarly situated,

               Plaintiffs – Appellees,

v.

ROBERT M. KERR, in his official capacity as Director, South Carolina Department
of Health and Human Services,

               Defendant – Appellant.

------------------------------

REPRODUCTIVE RIGHTS AND JUSTICE ORGANIZATIONS AND ALLIED
ORGANIZATIONS; NATIONAL HEALTH LAW PROGRAM; SOUTH
CAROLINA APPLESEED LEGAL JUSTICE CENTER; VIRGINIA POVERTY
LAW CENTER; NORTH CAROLINA JUSTICE CENTER; CHARLOTTE
CENTER FOR LEGAL ADVOCACY; IPAS; SEXUALITY INFORMATION
AND EDUCATION COUNCIL OF THE UNITED STATES; AMERICAN
ACADEMY OF FAMILY PHYSICIANS; AMERICAN ACADEMY OF
PEDIATRICS; AMERICAN COLLEGE OF NURSE-MIDWIVES; AMERICAN
COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS; AMERICAN
COLLEGE OF PHYSICIANS; AMERICAN MEDICAL ASSOCIATION;
AMERICAN PSYCHIATRIC ASSOCIATION; NURSE PRACTITIONERS IN
WOMENS HEALTH; SOCIETY FOR MATERNAL-FETAL MEDICINE;
SOCIETY OF GYNECOLOGIC ONCOLOGY; SOCIETY OF OB/GYN
HOSPITALISTS,

               Amici Supporting Appellee.
Appeal from the United States District Court for the District of South Carolina, at
Columbia. Mary G. Lewis, District Judge. (3:18-cv-02078-MGL)

Argued: January 26, 2022                                      Decided: March 8, 2022

Before WILKINSON, WYNN, and RICHARDSON, Circuit Judges.

Affirmed by published opinion. Judge Wilkinson wrote the opinion, in which Judge Wynn
joined. Judge Richardson wrote an opinion concurring in the judgment.

ARGUED: John J. Bursch, ALLIANCE DEFENDING FREEDOM, Washington, D.C.,
for Appellant. Nicole A. Saharsky, MAYER BROWN, LLP, Washington, D.C., for
Appellees. ON BRIEF: Kelly M. Jolley, Ariail B. Kirk, JOLLEY LAW GROUP, LLC,
Columbia, South Carolina, for Appellant. Avi M. Kupfer, MAYER BROWN LLP,
Chicago, Illinois; Alice Clapman, PLANNED PARENTHOOD FEDERATION OF
AMERICA, Washington, D.C.; M. Malissa Burnette, Kathleen McDaniel, BURNETTE,
SHUTT & MCDANIEL, PA, Columbia, South Carolina, for Appellees. Julie Rikelman,
Pilar Herrero, Joel Dodge, CENTER FOR REPRODUCTIVE RIGHTS, New York, New
York; Da Hae Kim, NATIONAL ASIAN PACIFIC AMERICAN WOMEN’S FORUM,
Washington, D.C., for Amici Reproductive Rights and Justice Organizations and Allied
Organizations. Martha Jane Perkins, Catherine McKee, Sarah Jane Somers, Sarah Grusin,
NATIONAL HEALTH LAW PROGRAM, Chapel Hill, North Carolina, for Amici The
National Health Law Program, South Carolina Appleseed Legal Justice Center, Virginia
Poverty Law Center, North Carolina Justice Center, Charlotte Center for Legal Advocacy,
IPAS, and Sexuality Information and Education Council of the United States. Janice M.
Mac Avoy, Alexis R. Casamassima, Danielle M. Stefanucci, FRIED, FRANK, HARRIS,
SHRIVER & JACOBSON LLP, New York, New York, for Amici American Academy of
Family Physicians, American Academy of Pediatrics, American College of Nurse-
Midwives, American College of Obstetricians and Gynecologists, American College of
Physicians, American Medical Association, American Psychiatric Association, Nurse
Practitioners in Women’s Health, Society for Maternal-Fetal Medicine, Society of
Gynecologic Oncology, and Society of OB/GYN Hospitalists.

                                          2
WILKINSON, Circuit Judge:

       This case arises out of South Carolina’s termination of Planned Parenthood South

Atlantic’s Medicaid provider agreement, an action that South Carolina took because

Planned Parenthood offers abortion services. But this case is not about abortion. It is about

Congress’s desire that Medicaid recipients have their choice of qualified Medicaid

providers.   Here   South    Carolina    terminated   Planned    Parenthood’s       agreement

notwithstanding the fact that all parties agree that Planned Parenthood is perfectly

competent to provide the non-abortive healthcare the individual plaintiff sought and

requested. To allow the State to disqualify Planned Parenthood would nullify Congress’s

manifest intent to provide our less fortunate citizens the opportunity to select a medical

provider of their choice, an opportunity that the most fortunate routinely enjoy.

       At the outset of this litigation, the district court issued a preliminary injunction

preventing South Carolina from terminating Planned Parenthood’s provider agreement. We

affirmed its decision then. South Carolina now returns to our court to appeal the district

court’s subsequent permanent injunction. For the following reasons, we again affirm the

district court’s judgment.

                                              I.

                                              A.

       Congress created Medicaid in 1965 to provide “federal financial assistance to States

that choose to reimburse certain costs of medical treatment for needy persons.” Harris v.

McRae, 448 U.S. 297, 301 (1980). The program furnishes “medical assistance on behalf of

                                             3
families with dependent children and of aged, blind, or disabled individuals, whose income

and resources are insufficient to meet the costs of necessary medical services.” 42 U.S.C.

§ 1396-1. In this way, Medicaid effectively serves as a nationwide system of public health

insurance for those who cannot afford medical care on their own.

      Although it is federal in scope, Medicaid is administered by the states and, “[l]ike

other Spending Clause legislation, Medicaid offers the States a bargain: Congress provides

federal funds in exchange for the States’ agreement to spend them in accordance with

congressionally imposed conditions.” Armstrong v. Exceptional Child Ctr., Inc., 575 U.S.

320, 323 (2015). The scheme of the Medicaid program reflects the cooperative nature of

this enterprise. Under the Medicaid Act, the federal government is tasked with crafting

general eligibility requirements and standards. See 42 U.S.C. § 1396 et seq. States then

submit Medicaid plans for approval by the Secretary of Health and Human Services, who

reviews these plans to ensure that they comply with the statutory and regulatory

requirements governing Medicaid. See Douglas v. Indep. Living Ctr. of S. Cal., Inc., 565

U.S. 606, 610 (2012). Upon approval, states receive federal matching funds that they may

use to reimburse providers. See id. at 611. On the other hand, the Secretary may withhold

funds if he finds “that in the administration of the plan there is a failure to comply

substantially” with the requirements of the Medicaid Act. 42 U.S.C. § 1396c.

      Over the first two years of the Medicaid program, Congress grew concerned that

states might deny recipients the opportunity to choose the provider of their choice. In

Puerto Rico, for instance, indigent patients could receive medical services “only in

Commonwealth facilities.” President’s Proposals for Revision in the Social Security

                                            4
System: Hearing on H.R. 5710 before the H. Comm. on Ways & Means, Part 4, 90th Cong.

2273 (1967). And in Massachusetts, private physicians at teaching hospitals were not

reimbursed under Medicaid. Id. at 2301.

       Accordingly, Congress amended the Medicaid Act to include the free-choice-of-

provider provision, which is at issue here. That provision states:

       A State plan for medical assistance 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 . . . who undertakes to provide him such
       services. . . .

42 U.S.C. § 1396a(a)(23).

                                              B.

       Planned Parenthood South Atlantic offers patients a number of family planning and

reproductive health services at two South Carolina health centers in Charleston and

Columbia. These services include, for instance, contraception and contraceptive

counseling, cancer screenings, screenings and treatment for sexually transmitted infections,

pregnancy testing, and physical exams. Planned Parenthood also performs abortions,

although South Carolina Medicaid only covers abortions in certain rare circumstances

required by federal law, such as rape, incest, or the need to protect the mother’s life. See

Consolidated Appropriations Act, 2021, Pub. L. No. 116–260, div. H, tit. V, §§ 506–07,

134 Stat. 1182, 1622 (Hyde Amendment).

       Julie Edwards, the individual plaintiff in this case, is insured through Medicaid and

suffers from Type 1 diabetes, for which she has obtained frequent medical attention. She

has been advised by doctors that, due to high blood pressure and high blood sugar, it would

                                              5
be dangerous for her to try to carry a pregnancy to term. After finding that local Medicaid

providers were unable or unwilling to provide her with the contraceptive care that she

sought, Edwards made an appointment at Planned Parenthood’s office in Columbia.

Doctors there inserted an intrauterine device to prevent pregnancy and told her that her

blood pressure was very high, for which she sought follow-up care. Edwards was impressed

with her visit and planned to shift “all [her] gynecological and reproductive health care

there,” including her “annual well woman exam.” J.A. 61. However, she stated that she

“[would] not be able to continue going there if the services are not covered” by Medicaid

and she is required “to pay out of pocket.” J.A. 61.

       In July 2018, the Governor of South Carolina issued an executive order directing

South Carolina’s Department of Health and Human Services (DHHS) “to deem abortion

clinics . . . that are enrolled in the Medicaid program as unqualified to provide family

planning services and, therefore, to immediately terminate them upon due notice and deny

any future such provider enrollment applications for the same.” J.A. 54. The Governor

stated that the purpose of this decision was to prevent South Carolina from indirectly

subsidizing the practice of abortion. On that same day, DHHS sent Planned Parenthood a

letter stating that it was “no longer . . . qualified to provide services to Medicaid

beneficiaries” and that its “enrollment agreements with the South Carolina Medicaid

programs [were] terminated” effective immediately. J.A. 56.

       Two weeks later, Planned Parenthood and Edwards filed suit under 42 U.S.C.

§ 1983 against the Director of DHHS in federal district court, alleging that South Carolina

had violated the Medicaid Act and the Fourteenth Amendment. The plaintiffs soon moved

                                             6
for a preliminary injunction and a temporary restraining order, contending that they were

likely to succeed on their claim that South Carolina’s termination of Planned Parenthood’s

Medicaid provider agreement violated the Medicaid Act’s free-choice-of-provider

provision. South Carolina opposed this motion, arguing that the plaintiffs lacked a cause

of action under § 1983 to sue to enforce that provision.

       The district court granted the preliminary injunction, concluding that Edwards had

demonstrated that she was likely to succeed on her Medicaid Act claim since the free-

choice-of-provider provision conferred a private right enforceable under § 1983 and since

South Carolina had violated that provision by terminating Planned Parenthood’s Medicaid

provider agreement. See Planned Parenthood S. Atl. v. Baker, 326 F. Supp. 3d 39, 44–48

(D.S.C. 2018). The district court concluded that the other equitable factors also favored

Edwards and it enjoined South Carolina from terminating Planned Parenthood’s provider

agreement during the pendency of the litigation. See id. at 48–50. Because it held that

preliminary relief was warranted on the basis of Edwards’s Medicaid Act claim, it declined

to consider whether such relief would also be appropriate on the basis of Planned

Parenthood’s claim. See id. at 50.

       South Carolina appealed and this panel affirmed. Planned Parenthood S. Atl. v.

Baker, 941 F.3d 687, 691 (4th Cir. 2019). After applying the three factors articulated by

the Supreme Court in Blessing v. Firestone, 520 U.S. 329 (1997), we first concluded that

the free-choice-of-provider provision conferred on Edwards a private right enforceable

under § 1983. See Baker, 941 F.3d at 696–98. We noted that the statute was couched in

terms of individual beneficiaries and that it used the phrase “any individual,” indicating

                                             7
Congress’s specific intention to confer a right on the class of Medicaid recipients. Id. at

697. In addition, the statute was not so “vague and amorphous” as to strain judicial

competence and the text clearly imposed a “binding obligation on the States.” Id. (quoting

Blessing, 520 U.S. at 340–41). Since the enforcement scheme did not indicate that

Congress had foreclosed a remedy under § 1983, we concluded that Edwards could sue

under that statute to enforce the free-choice-of-provider provision. See id. at 698–700.

       Next, we determined that a provider was “qualified to perform the service or

services required” under the terms of the statute, 42 U.S.C. § 1396a(a)(23), if it was

professionally competent to do so, although states retained discretionary authority to

disqualify providers as professionally incompetent. See id. at 701–06. Since South

Carolina’s exclusion of Planned Parenthood had “nothing to do with professional

misconduct” or with Planned Parenthood’s “ability to safely and professionally perform

plaintiff’s required family-planning services,” we agreed with the district court that

Edwards had demonstrated a substantial likelihood of success on her Medicaid Act claim.

Id. at 705. Likewise, we concluded that the district court had not abused its discretion in

determining that the remaining equitable factors favored Edwards and we affirmed its

judgment. See id. at 706–07.

       Following our decision, South Carolina petitioned for a writ of certiorari, which the

Supreme Court denied. Baker v. Planned Parenthood S. Atl., 141 S. Ct. 550 (2020). The

district court subsequently granted summary judgment to the plaintiffs on Edwards’s

Medicaid Act claim, noting that, under this panel’s previous decision, “Edwards, as a

matter of law, may seek to enforce the free-choice-of-provider provision in this § 1983

                                             8
action” and that it was “required to follow Fourth Circuit precedent” on this question.

Planned Parenthood S. Atl. v. Baker, 487 F. Supp. 3d 443, 446, 448 (D.S.C. 2020). Since

it concluded that South Carolina had violated this provision, the district court entered

summary judgment for the plaintiffs. See id. The parties stipulated to a dismissal of their

remaining Fourteenth Amendment claims, following which the district court entered a

declaratory judgment in favor of the plaintiffs and “permanently enjoined” South Carolina

“from terminating or excluding [Planned Parenthood] from participation in the South

Carolina Medicaid Program on the grounds it is an abortion clinic or provides abortion

services.” J.A. 302–03. South Carolina now appeals.

                                               II.

       Before we turn to the merits of South Carolina’s appeal, however, we must satisfy

ourselves that we have jurisdiction. South Carolina contends for the first time on this appeal

that it believes this case is moot. We do not share that view.

       Under Article III of the Constitution, our jurisdiction is limited to “the adjudication

of actual cases and controversies.” Mellen v. Bunting, 327 F.3d 355, 363 (4th Cir. 2003).

This requirement “extends throughout the pendency of the action,” id., and “a case is moot

when the issues presented are no longer ‘live’ or the parties lack a legally cognizable

interest in the outcome,” Powell v. McCormack, 395 U.S. 486, 496 (1969). As such,

mootness is closely related to standing and we have made clear that “a case is moot if, at

any point prior to the case’s disposition, one of the elements essential to standing, like

                                              9
injury-in-fact, no longer obtains.” Am. Fed’n of Gov’t Emps. v. Office of Special Counsel,

1 F.4th 180, 187 (4th Cir. 2021).

       To establish standing, the plaintiff must allege an injury that is “concrete,

particularized, and actual or imminent; fairly traceable to the challenged action; and

redressable by a favorable ruling.” Monsanto Co. v. Geertson Seed Farms, 561 U.S. 139,

149 (2010). In its reply brief, South Carolina alleges for the first time that Edwards no

longer satisfies these requirements, on the grounds that she has not used Planned

Parenthood’s services since filing her complaint and therefore faces no concrete injury if

South Carolina terminates Planned Parenthood’s Medicaid provider agreement. Although

this contention is offered late in the day, we are bound to consider it fully.

       Upon doing so, however, we are satisfied that Edwards’s claims are not moot. It is

uncontested that Edwards is insured through Medicaid and that she has previously relied

on Planned Parenthood for gynecological and reproductive healthcare. In addition,

Edwards asserts in a supplemental declaration that she has seen no other providers for such

care since her appointment with Planned Parenthood in 2018. In this declaration, executed

in July of last year, Edwards states that she in fact had made an appointment for future care

with Planned Parenthood before learning of South Carolina’s mootness argument. If

Planned Parenthood is not able to provide this care under Medicaid, Edwards will be forced

to look elsewhere and she will experience a concrete, particularized injury.

       South Carolina has not undermined Edwards’s declaration or the contents thereof;

instead, it suggests that her stated intentions to seek care from Planned Parenthood are

insufficient to establish a concrete or imminent injury for Article III purposes. But a future

                                              10
injury satisfies Article III as long as “the threatened injury is certainly impending, or there

is a substantial risk that the harm will occur.” Dep’t of Commerce v. New York, 139 S. Ct.

2551, 2565 (2019) (quoting Susan B. Anthony List v. Driehaus, 573 U.S. 149, 158 (2014)).

Here there is a substantial risk that Edwards will be harmed, given that she has previously

used Planned Parenthood for gynecological and reproductive care, has seen no other

providers for this care since, and has made a future appointment to receive this care from

Planned Parenthood. And while Edwards may not have visited Planned Parenthood as

regularly as she predicted in her complaint, the frequency of medical appointments may

not be so perfectly predicted in advance. It is commonplace for patients to see multiple

providers and equally routine to defer care until the need arises or until symptoms in some

way manifest themselves. We are given no reason to doubt Edwards’s contention that she

intends Planned Parenthood to be her medical provider for certain forms of healthcare. The

fact that she did not require such care in the time between the outset of this litigation and

the present may simply reflect the happenstance of medical need, coupled with the unique

hindrances of the covid pandemic.

       We note that our conclusion here is a narrow one, drawn from the particular facts of

Edwards’s situation. And we are fully mindful of the Supreme Court’s admonition that

“‘some day’ intentions—without any description of concrete plans, or indeed even any

specification of when the some day will be—do not support a finding of the ‘actual or

imminent’ injury that our cases require.” Lujan v. Defs. of Wildlife, 504 U.S. 555, 564

(1992). Here, however, Edwards has made just the “concrete plans” that Lujan requires.

And while the plaintiffs in Lujan asserted injury on the basis of abstract and indefinite

                                              11
intentions to visit certain countries, see id., it is far more likely that Edwards will fulfill her

stated intention to seek gynecological or reproductive care from Planned Parenthood in the

future, given the fact that Planned Parenthood’s proximity and match with her medical

needs led her to seek its services in the past. Under the particular circumstances present

here, we conclude this case presents a live case or controversy. To hold otherwise would

be to deprive Edwards both of the access to court which is her due and of the access to her

chosen qualified medical provider.

                                                 III.

       On the merits, South Carolina argues that we should reconsider our previous panel

decision and hold that Edwards cannot sue under § 1983 to enforce the free-choice-of-

provider provision. 1 In essence, South Carolina suggests that we reverse the district court

for applying a legal conclusion that we previously set forth in a binding opinion. This is a

striking request, and one that cannot be reconciled with the nature of precedent in our

judicial system. In any event, we remain persuaded that our previous holding is correct and

we take this opportunity to reaffirm our prior decision.

                                                 A.

       In asking us to reconsider our previous decision, South Carolina would deny it any

precedential weight. The State’s position here is quite misguided. While law is indeed not

       1
        Notably, South Carolina does not challenge the district court’s determination (and
our own previous conclusion) that South Carolina violated this provision by terminating
Planned Parenthood’s Medicaid provider agreement.
                                                12
static, it is also not open to reversal in the manner that appellant suggests. After all, the

question at issue here is identical to the legal question we resolved in the prior case: whether

§ 1983 provides a cause of action to enforce the Medicaid Act’s free-choice-of-provider

provision. We answered that question as a legal matter after full briefing and oral argument,

and we presented our conclusion in a published opinion. Such a decision “is binding on

other panels unless it is overruled by a subsequent en banc opinion of the court or a

superseding contrary decision of the Supreme Court.” United States v. Dodge, 963 F.3d

379, 383 (4th Cir. 2020) (quoting United States v. Collins, 415 F.3d 304, 311 (4th Cir.

2005)).

       South Carolina points to no such en banc opinion or Supreme Court decision.

Instead, the only intervening change highlighted by South Carolina is that the Fifth Circuit

recently came to a different conclusion than our own. See Planned Parenthood of Greater

Tex. Family Planning & Preventative Health Servs., Inc. v. Kauffman, 981 F.3d 347, 353

(5th Cir. 2020) (en banc). Even setting aside the fact that we remain on the majority of a

rather lopsided circuit split, 2 it is hard to see how that could justify our reconsideration of

the case. If we were free to overturn our own prior position whenever another circuit took

a different view, it would utterly destabilize the law of our circuit, placing it at the

sufferance of any circuit court anywhere that took a contrary step—something that often

       2
          Compare Planned Parenthood of Kan. v. Andersen, 882 F.3d 1205, 1224 (10th
Cir. 2018); Planned Parenthood Ariz. Inc. v. Betlach, 727 F.3d 960, 965–66 (9th Cir.
2013); Planned Parenthood of Ind., Inc. v. Comm’r of Ind. State Dep’t of Health, 699 F.3d
962, 968 (7th Cir. 2012); Harris v. Olszewski, 442 F.3d 456, 461 (6th Cir. 2006) (all finding
a right of action under § 1983) with Kauffman, 981 F.3d at 353; Does v. Gillespie, 867 F.3d
1034, 1037 (8th Cir. 2017) (finding no right of action under § 1983).
                                              13
happens between the courts of appeals. As useful as we may find decisions from the other

circuits, they of course carry only persuasive weight in our own.

       Against these pressing considerations, South Carolina suggests that the law-of-the-

circuit framework is inapposite here. It contends instead that only law-of-the-case governs

where a panel rehears a legal issue stemming from the same case as a prior opinion. But

we need not dance on the head of a pin as to whether our previous decision implicates law-

of-the-case or whether it’s binding law-of-the-circuit. As between the two, South Carolina

loses either way. Without exception, this court has understood that the resolution of a

purely legal issue, absent a change in controlling law, governs subsequent panels, including

in later appeals following a prior interlocutory appeal. L.J. v. Wilbon, 633 F.3d 297, 308

(4th Cir. 2011); U.S. Dep’t of Hous. & Urban Dev. v. Cost Control Mktg. & Sales Mgmt.

of Va., Inc., 64 F.3d 920, 925 (4th Cir. 1995); see also Tatum v. RJR Pension Inv. Comm.,

855 F.3d 553, 560 n.5 (4th Cir. 2017) (noting that a previous opinion by an identical panel

in the same case constituted both “law of the case” and “Fourth Circuit precedent”). We

are hardly alone in this understanding. See Howe v. City of Akron, 801 F.3d 718, 740 (6th

Cir. 2015) (collecting cases from the other courts of appeals).

       “What has once been settled by a precedent will not be unsettled overnight, for

certainty and uniformity are gains not lightly to be sacrificed.” Benjamin N. Cardozo, The

Paradoxes of Legal Science 29–30 (1928). Justice Cardozo’s predecessor on the Supreme

Court was of the same mind and once commented, in response to an article criticizing the

common law: “We must add that we sincerely hope that the editors will fail in their

expressed desire to diminish the weight of precedents with our courts. We believe the

                                            14
weight attached to them is about the best thing in our whole system of law.” Oliver Wendell

Holmes Jr., Summary of Events, 7 Am. L. Rev. 579, 579 (1873). We agree with our

forebears. Our fidelity to our previous decisions is a necessary service to the parties before

us, as well as to the public generally. It ensures stability in the law and provides clear

signals to litigants so that they may rely on our decisions. The alternative is a legal system

where each thing is up for grabs every time. The very guidance that law purports to provide

for human conduct would by degrees recede. So even assuming, purely arguendo, that we

were free to reexamine our precedents, we would not do so here. Our previous decision

was handed down as a matter of law and resolved the precise legal issue upon which South

Carolina now seeks review. For the above multiplicity of reasons we stand by it. In Latin:

stare decisis.

                                               B.

       Furthermore, we take this occasion to reaffirm our prior holding. To reiterate, the

legal question is whether individuals such as Edwards may sue under 42 U.S.C. § 1983 to

enforce the Medicaid Act’s free-choice-of-provider provision. Section 1983 provides that:

       Every person who, under color of any statute, ordinance, regulation, custom,
       or usage, of any State or Territory or the District of Columbia, subjects, or
       causes to be subjected, any citizen of the United States or other person within
       the jurisdiction thereof to the deprivation of any rights, privileges, or
       immunities secured by the Constitution and laws, shall be liable to the party
       injured . . . .

42 U.S.C. § 1983. The Supreme Court has interpreted the phrase “and laws” to provide a

cause of action for individuals who are deprived of a right, privilege, or immunity secured

by federal statute. Maine v. Thiboutot, 448 U.S. 1, 4 (1980). As the Supreme Court has

                                             15
cautioned, however, a litigant seeking to assert a cause of action under § 1983 “must assert

the violation of a federal right, not merely a violation of federal law.” Blessing, 520 U.S.

at 340.

          As we explained in our previous opinion, rights of action brought under § 1983 are

different from private rights of action inferred directly from a statute. See Baker, 941 F.3d

at 694–95. The Supreme Court has warned against readily finding statutory rights of action

under § 1983. It is not enough for a plaintiff to fall “within the general zone of interest” of

a federal statute. Gonzaga Univ. v. Doe, 536 U.S. 273, 283 (2002). Rather, nothing “short

of an unambiguously conferred right,” rather than the “broader or vaguer” notion of

“‘benefits’ or ‘interests’” may support a cause of action under § 1983. Id. This is

particularly important in the Spending Clause context since such legislation is akin to a

contract and “[t]he legitimacy of Congress’ power to legislate under the spending

power thus rests on whether the State voluntarily and knowingly accepts the terms of the

‘contract.’” Pennhurst State Sch. & Hosp. v. Halderman, 451 U.S. 1, 17 (1981). But where

it is clear and unambiguous that Congress intended to create a private right, we are obliged

to follow its intention. As we noted, “[c]ourts cannot deprive the sovereign signatories to

a ‘contract’ such as the Medicaid Act of the benefit of their bargain.” Baker, 941 F.3d at

701.

                                               1.

          In Blessing, the Supreme Court articulated three factors to determine whether a

statute creates a private right enforceable under § 1983:

                                              16
       First, Congress must have intended that the provision in question benefit the
       plaintiff. Second, the plaintiff must demonstrate that the right assertedly
       protected by the statute is not so “vague and amorphous” that its enforcement
       would strain judicial competence. Third, the statute must unambiguously
       impose a binding obligation on the States. In other words, the provision
       giving rise to the asserted right must be couched in mandatory, rather than
       precatory terms.

520 U.S. at 340–41 (citations omitted). If these three factors are satisfied, there is “a

rebuttable presumption that the right is enforceable under § 1983,” provided that Congress

has not expressly or implicitly foreclosed a § 1983 remedy. Id. at 341.

       To repeat, the free-choice-of-provider provision states that “[a] State plan for

medical assistance must . . . provide that any individual eligible for medical assistance . . .

may obtain such assistance from any institution . . . qualified to perform the service or

services required.” 42 U.S.C. § 1396a(a)(23) (emphases added). “It is difficult to imagine

a clearer or more affirmative directive.” Baker, 941 F.3d at 694. The statute plainly reflects

Congress’s desire that individual Medicaid recipients be free to obtain care from any

qualified provider and it implements this policy in direct and unambiguous language. For

this reason, all three of the Blessing factors are met.

       As to the first factor, the free-choice-of-provider provision “unambiguously gives

Medicaid-eligible patients an individual right” to their choice of qualified provider.

Planned Parenthood of Ind., Inc. v. Comm’r of Ind. State Dep’t of Health, 699 F.3d 962,

974 (7th Cir. 2012). The provision clearly and expressly identifies the intended

beneficiaries: “any individual eligible for medical assistance” under Medicaid. 42 U.S.C.

§ 1396a(a)(23)(A). And as we noted, “Congress’s use of the phrase ‘any individual’ is a

prime example of the kind of ‘rights-creating’ language required to confer a personal right

                                              17
on a discrete class of persons—here, Medicaid beneficiaries.” Baker, 941 F.3d at 697.

Indeed, this phrase closely mirrors the common example that the Supreme Court has given

of such language. See Gonzaga, 536 U.S. at 287 (“No person . . . shall . . . be subjected to

discrimination.”). The statutory text therefore unmistakably evinces Congress’s intention

to confer on Medicaid beneficiaries a right to the free choice of their provider.

       As to the second factor, the provision is hardly so “vague and amorphous” as to

preclude judicial enforcement, Blessing, 520 U.S. at 340, since it merely requires courts to

make two discrete assessments: (i) that the provider is “qualified to perform the service or

services required” and (ii) that the provider “undertakes” to provide those services, 42

U.S.C. § 1396a(a)(23)(A). By way of comparison, the Supreme Court has concluded that

a statute does not confer an enforceable right where it simply required a state to make

“‘reasonable efforts’ to maintain an abused or neglected child in his home” without any

“further statutory guidance.” Suter v. Artist M., 503 U.S. 347, 359–60 (1992). Here, by

contrast, the statute does not require courts to “engage in any balancing of competing

concerns or subjective policy judgments, but only to answer factual, yes-or-no questions:

Was an individual denied the choice of a (1) qualified and (2) willing provider?” Planned

Parenthood Ariz. Inc. v. Betlach, 727 F.3d 960, 967 (9th Cir. 2013). Courts are routinely

tasked with resolving questions just like these.

       Indeed, the facts of this case make it particularly easy to apply the free-choice-of-

provider provision. Planned Parenthood has provided the medical services that Edwards

seeks for almost four decades, without any apparent challenge to its professional

competence until now. We of course would give due respect and weight to South Carolina’s

                                             18
judgment that a particular provider is unqualified. But the language of the statute makes

clear that the relevant qualifications are medical qualifications, and, as we noted in our

prior decision, South Carolina “does not the contest the fact” that Planned Parenthood “is

professionally qualified to deliver the services that the individual plaintiff seeks.” Baker,

941 F.3d at 702. Given these facts, it is straightforward to apply the free-choice-of-provider

provision here.

       Finally, as to the third factor, the statute is couched in just the “mandatory, rather

than precatory terms” that the Supreme Court has required, Blessing, 520 U.S. at 341, since

states “must provide” a Medicaid recipient with her choice of qualified provider. Again, a

comparison makes the point clear: the Supreme Court found that provisions “were intended

to be hortatory, not mandatory” where they were expressed only as “findings respecting

the rights of persons with developmental disabilities,” such as that these persons have a

right to “appropriate treatment.” Pennhurst, 451 U.S. at 13, 24. Here, by contrast, the text

clearly imposes a definite obligation on state governments; indeed, it is hard to imagine

how Congress could have more plainly used mandatory language.

       In short, if this statute does not survive the Blessing factors, we cannot imagine one

that would. Congress used emphatic, mandatory language to affirm the right of Medicaid

recipients to receive the healthcare of their choice from a willing provider, and there is

nothing about this inquiry that would strain the judicial role. In every respect, the statute

resembles those laws which the Supreme Court has determined confer enforceable rights

and we do not see how we could hold otherwise without repudiating Congress’s clear

intention.

                                             19
       In fact, South Carolina does not dispute our analysis of the Blessing factors. Rather,

it argues that we erred altogether in applying these factors and suggests that the Supreme

Court’s decision in Gonzaga effectively abrogated Blessing. But Gonzaga never indicated

that Blessing is no longer good law; instead, it simply criticized courts that interpreted

Blessing “as allowing plaintiffs to enforce a statute under § 1983 so long as the plaintiff

falls within the general zone of interest that the statute is intended to protect.” 536 U.S. at

282–83. Indeed, our court has held that the Blessing factors continue to govern following

Gonzaga. Doe v. Kidd, 501 F.3d 348, 355 (4th Cir. 2007).

       While South Carolina contends we disregarded Gonzaga in our prior decision, we

in fact took pains to heed Gonzaga’s instruction that there must be an “unambiguously

conferred right to support a cause of action brought under § 1983.” Gonzaga, 536 U.S. at

283; see Baker, 941 F.3d at 695, 697, 700. As we stated, “courts are most definitely not at

liberty to imply private rights of action willy-nilly.” Baker, 941 F.3d at 700. But where

Congress’s intent to make a right enforceable under § 1983 is indeed “clear and

unambiguous,” Gonzaga, 536 U.S. at 290, we are bound to respect it. Because Congress’s

intent is clear and unambiguous here, we conclude that the free-choice-of-provider

provision confers on Medicaid recipients an individual right.

                                               2.

       Since the Blessing factors are satisfied, the free-choice-of-provider provision may

be enforced under § 1983 unless the Medicaid Act evinces Congress’s intent to

“specifically foreclose[] a remedy under § 1983.” Blessing, 520 U.S. at 341 (quoting Smith

v. Robinson, 468 U.S. 992, 1005 n.9 (1984)). “We do not lightly conclude that Congress

                                              20
intended to preclude reliance on § 1983 as a remedy.” Smith, 468 U.S. at 1012. And as we

explained at length in our previous opinion, the statute here does no such thing. See Baker,

941 F.3d at 698–700.

       The Medicaid Act provides three potential remedies in this context: the Secretary of

Health & Human Services may take the drastic step of cutting off Medicaid funds,

providers may follow state administrative processes to challenge termination decisions, or

Medicaid recipients may use similar procedures to challenge claim denials. See id. at 698.

None of these remedies provides individual Medicaid recipients any mechanism to contest

the disqualification of their preferred provider, even though the statutory language benefits

these individual recipients specifically and even though the Supreme Court has instructed

us to focus on whether “an aggrieved individual lack[s] any federal review mechanism.”

Gonzaga, 536 U.S. at 290. And as we noted previously, see Baker, 941 F.3d at 698–99, the

Supreme Court has already held in Wilder v. Virginia Hospital Ass’n, 496 U.S. 498 (1990),

that the Medicaid Act does not foreclose remedies under § 1983 for just these reasons, see

id. at 521–23.

       In response, South Carolina argues that we erroneously relied on Wilder and that

this decision has been repudiated by the Supreme Court. This suggestion misreads both our

previous decision and the Supreme Court’s discussion of Wilder. To be sure, § 1983 does

not operate as some sort of ubiquitous backstop conferring a private right of action where

the underlying statute fails to do so. The Court has made clear that we should not rely on

Wilder’s mode of analysis in determining whether a statute confers a private right

enforceable under § 1983. See Gonzaga, 536 U.S. at 283 (rejecting the view “that our cases

                                             21
permit anything short of an unambiguously conferred right to support a cause of action

brought under § 1983”); Armstrong, 575 U.S. at 330 n* (noting that “our later opinions

plainly repudiate the ready implication of a § 1983 action that Wilder exemplified”). But

the Supreme Court has never extended this criticism to Wilder’s subsequent analysis as to

whether a statute’s remedial scheme forecloses the enforcement of a plainly conferred

cause of action under § 1983. In fact, the Court approvingly cited Wilder on this point

following Gonzaga. See City of Ranchos Palos Verdes v. Abrams, 544 U.S. 113, 122

(2005).

       Suffice it to say that it is difficult to imagine that Congress would have passed such

an emphatic provision and yet would not have approved some private enforcement

mechanism on the part of those very people whom the statute was designed to benefit. It

would be an odd state of affairs if Congress had categorically precluded enforcement on

the part of these very beneficiaries, and there is nothing in the statute to suggest that it did.

                                                3.

       Finally, we conclude that the Supreme Court’s decision in O’Bannon v. Town Court

Nursing Center, 447 U.S. 773 (1980), does not undermine this analysis. South Carolina

interprets O’Bannon to hold that the free-choice-of-provider provision does not confer any

individual rights on Medicaid recipients. But that case actually resolved an entirely

different question and, to the extent that it has any application here, it only supports the

existence of a private right.

       In O’Bannon, the plaintiffs were residents of a nursing home who argued that they

were entitled under the Due Process Clause to a hearing before the government decertified

                                               22
their home. See id. at 775–77. The state sought to do so upon the recommendation of the

federal government and had cited a number of reasons for decertification, all of which had

to do with professional competence. See id. at 775–76 & n.3. The plaintiffs did not argue

that they could sue to enforce the terms of the Medicaid Act but only that the Act granted

them a “property right to remain in the home of their choice absent good cause for transfer”

or that such a transfer would deprive them of life or liberty. Id. at 784. So, as we noted

previously, see Baker, 741 F.3d at 704, the Supreme Court had no reason to consider the

existence or scope of a statutory cause of action to enforce the Medicaid Act, and none of

its reasoning bears on that question. The Court simply rejected the procedural due process

claim brought by the plaintiffs, concluding that the decertification of an unqualified facility

“does not amount to a deprivation of any interest in life, liberty, or property.” O’Bannon,

447 U.S. at 787.

       O’Bannon therefore has little to do with this case. But to the extent that it is at all

applicable, language from that decision only supports the plaintiff’s position here. While

the Court rejected the notion that plaintiffs might possess some constitutional interest to

receive benefits from an unqualified provider, it repeatedly indicated that the free-choice-

of-provider provision “gives recipients the right to choose among a range of qualified

providers without government interference.” Id. at 785; see also id. n.18 (noting that “the

statute referred to above would prohibit any . . . interference with the patient’s free choice

among qualified providers”). As the Court made clear, a patient has “no enforceable

expectation of continued benefits to pay for care in an institution that has been determined

to be unqualified” but does have “a right to continued benefits to pay for care in the

                                              23
qualified institution of his choice.” Id. at 786. Here, of course, the issue is precisely that

Planned Parenthood remains a qualified institution under the terms of the statute, and South

Carolina’s termination of its Medicaid provider agreement impinges on Edwards’s “right

to choose among a range of qualified providers without government interference.” Id. at

785.

                                               IV.

       In sum we refuse to nullify Congress’s undeniable desire to extend a choice of

medical providers to the less fortunate among us, individuals who experience the same

medical problems as the more fortunate in society but who lack under their own means the

same freedom to choose their healthcare provider. In the Medicaid Act, Congress attempted

a modest corrective to this imbalance. If we were to restrict the opportunity that these

individuals have to access prenatal care that would both assist the mother and help bring

healthy babies into this world, we would be reaching what we think is a legally

impermissible result.

       For the foregoing reasons, the judgment of the district court is

                                                                                AFFIRMED.

                                             24
RICHARDSON, Circuit Judge, concurring in the judgment:

       Despite some reservations, I agree that the case is not moot given the facts before

this Court. The State’s attempt to introduce information outside the record, which allegedly

comes from an internal database, cannot establish mootness.

       I also continue to believe that “applying existing Supreme Court precedents requires

that we find § 1396a(a)(23) to unambiguously create a right privately enforceable under

§ 1983 to challenge a State’s determination of whether a Medicaid provider is ‘qualified.’”

Planned Parenthood S. Atl. v. Baker, 941 F.3d 687, 707 (4th Cir. 2019) (Richardson, J.,

concurring). As a result, it matters not whether our previous decision is binding circuit

precedent or the “law of the case.” I would reach the same result either way.

       At the same time, the caselaw on implied private rights of action remains plagued

by confusion and uncertainty. Id. at 708–10. This confusion stems from recent Supreme

Court cases which cast doubt on—but fail to explicitly overrule—earlier precedent.

Gonzaga arguably laid down a different test than Wilder and Blessing. See Gonzaga Univ.

v. Doe, 536 U.S. 273, 283 (2002). And Armstrong v. Exceptional Child Ctr., Inc., 575 U.S.

320, 330 n.* (2015), questioned Wilder’s reasoning and claimed later opinions “plainly

repudiate” its “ready implication of a § 1983 action.” Yet this Court remains bound by

Blessing and Wilder. Baker, 941 F.3d at 709–10 (Richardson, J., concurring). So I am left

hoping that clarity will soon be provided.

                                             25