Saint Louis University Journal of Health Law & Policy

Document Type



During the twentieth century, Congress enacted legislation designed to improve the lives of low-income Americans. A number of these laws were enacted by Congress pursuant to the Constitution’s Spending Clause, including the Medicaid Act, which entitles certain low-income individuals to publicly funded health insurance coverage. As enacted in 1965, the Medicaid Act did not include a provision authorizing the statute’s beneficiaries to bring private enforcement actions in court. Since the early 1970s, however, program beneficiaries relied upon the Constitution’s Supremacy Clause or, more frequently, 42 U.S.C. § 1983 for the cause of action allowing them to obtain relief in court. More recently, the Supreme Court has restricted private enforcement of Spending Clause enactments. This article discusses the judicial and legislative actions affecting private enforcement under the Supremacy Clause and Section 1983. It then reviews Medicaid’s enforcement track record in the federal courts of appeals in light of these Supreme Court and congressional activities. Congress intends for program beneficiaries to be able to enforce provisions of the Medicaid Act, and, applying the Supreme Court’s traditional enforcement test under Section 1983, the appellate courts are consistently allowing certain Medicaid provisions to be enforced by program beneficiaries while refusing to allow enforcement of others.