Case Information
*2 Before NIEMEYER and HAMILTON, Circuit Judges, and Raymond A. JACKSON, United States District Judge for the Eastern District of Virginia, sitting by designation.
Affirmed by published opinion. Judge Niemeyer wrote the opinion, in which Senior Judge Hamilton and Judge Jackson joined. COUNSEL ARGUED: Ronald Moore Marquette, Special Deputy Attorney Gen- eral, NORTH CAROLINA DEPARTMENT OF JUSTICE, Raleigh, North Carolina, for Appellants. Martha Jane Perkins, NATIONAL HEALTH LAW PROGRAM, Chapel Hill, North Carolina, for Appel- lees. Alisa Beth Klein, Appellate Staff, Civil Division, UNITED STATES DEPARTMENT OF JUSTICE, Washington, D.C., for Amicus Curiae. ON BRIEF: Roy Cooper, North Carolina Attorney General, Robert J. Blum, Special Deputy Attorney General, Emery E. Milliken, Assistant Attorney General, NORTH CAROLINA DEPARTMENT OF JUSTICE, Raleigh, North Carolina, for Appel- lants. Reid C. Adams, Jr., WOMBLE, CARLYLE, SANDRIDGE & RICE, Winston-Salem, North Carolina; Garth Gersten, WOMBLE, CARLYLE, SANDRIDGE & RICE, Research Triangle Park, North Carolina; Carlene McNulty, NORTH CAROLINA JUSTICE & COMMUNITY DEVELOPMENT CENTER, Raleigh, North Caro- lina, for Appellees. Robert D. McCallum, Jr., Assistant Attorney Gen- eral, John Stuart Bruce, United States Attorney, Mark B. Stern, Appellate Staff, Civil Division, UNITED STATES DEPARTMENT OF JUSTICE, Washington, D.C., for Amicus Curiae.
OPINION
NIEMEYER, Circuit Judge:
Several North Carolina Medicaid beneficiaries commenced this class action under 42 U.S.C. § 1983 against North Carolina State offi- cials to obtain (1) a declaratory judgment that dental screening and treatment services provided to minors in North Carolina under the Medicaid program are inadequate and fail to comply with the require- ments of the Medicaid Act and (2) an injunction requiring the State officials to comply with the Medicaid Act by making dental screening and treatment promptly available. The district court, relying on Ex Parte Young , 209 U.S. 123 (1908), denied the North Carolina State officials’ motion to dismiss based on Eleventh Amendment immunity. The court also rejected the officials’ other jurisdictional challenges. On this interlocutory appeal, we affirm the district court’s ruling on Eleventh Amendment immunity, and we decline to exercise pendent appellate jurisdiction over the other grounds on which the State offi- cials relied to support their motion to dismiss the complaint.
I
The plaintiffs, who are minors, allege in their complaint that they havе been denied the dental care prescribed by Title XIX of the Social Security Act, known as the "Medicaid Act." Noting that only 16% of North Carolina’s dentists participate in the Medicaid program, they allege that they are unable to locate local dentists who are willing to treat them in exchange for Medicaid reimbursement. They assert that Medicaid beneficiaries in North Carolina generally must conduct extensive searches and travel long distances to locate and utilize the services of a dentist who will accept Medicaid reimbursement.
Describing their own experiences, Emani Tatum, 3, alleges that she has had to travel two hours each way to utilize the services of a den- tist. While a dental clinic closer to her provided an initial screening, that clinic was unable to provide ongoing care. As a result of the inac- cessibility of prompt and adequate care, she has had to have extensive dental care, including three fillings and two crowns. JeShod Hughes, 9, alleges that he has had similar difficulties in obtaining treatment. Arielle McCree, 6, alleges that her mother contacted the local Depart- ment of Social Services to find a dentist, only to be referred to the public health clinic, which was unable to provide dentаl services. The Department of Social Services then could not provide the name of any dentist for McCree who would accept Medicaid reimbursement. McCree’s mother eventually located a dentist an hour away. Austin Brooks, 6, alleges that his grandmother contacted numerous dentists in his area, but none would accept Medicaid. Because he could not locate a dentist in his area, he could not receive preventive dental treatment. When he began experiencing oral pain, his grandmother located a dentist three hours away. Because of the lack of preventative dеntal care, Brooks has had to have four of his front teeth pulled and several of his remaining teeth capped. [1]
Because of their inability to receive adequate dental care, these plaintiffs, through their parents, guardians, or next friends, com- menced this action on behalf of themselves and on behalf of others similarly situated against Carmen Hooker Buell, Director of the North Carolina Department of Health and Human Services, and Nina M. Yeager, Director of the North Carolina Division of Medicaid Assis- tance, in their official capacities. [2] Plaintiffs allege that the defendants have: (1) denied North Carolinа Medicaid beneficiaries equal access and quality care, in violation of 42 U.S.C. § 1396a(a)(30)(A) and 42 [1] With respect to the two Antrican plaintiffs, the parties agree that they are not presently eligible for benefits under the Medicaid program and that they will be dismissed from this action.
[2] North Carolina has chosen to participate in the federal Medicaid pro- gram and, therefore, agrees to follow the requirements of the Medicaid Act and accept federal funding for its Medicaid program. N.C. Gen. Stat. Ann. § 108A-56. Buell and Yeager are the North Carolina officials charged with administering the North Carolina Medicaid program.
Generally, the Medicaid Act provides conditional federal financial assistance to states that choose to participate in the Medicaid program. See 42 U.S.C. § 1396 et seq . The purpose of the program is to enable states "to furnish . . . medical assistance on behalf of families with dependent children . . . whose income and resources are insufficient to meet the costs of necessary medical services," and funds are available to "States which have submitted, and had approved by the Secretary [of the United States Department of Health and Human Services], State plans for medical assistance." 42 U.S.C. § 1396. Statеs are not required to par- ticipate in the Medicaid program, but if they choose to participate, and succeed in having their plans approved by the Secretary, they must implement and operate Medicaid programs that comply with detailed federally mandated standards. See 42 U.S.C. § 1396a. If a participating State fails to comply with federal standards, the Secretary may withhold federal funding from the State until it brings its plan back into compli- ance with those standards. See 42 U.S.C. § 1396c.
C.F.R. § 447.204; (2) failed to ensure statewide availability of dental services, in violation of 42 U.S.C. § 1396a(a)(1) and 42 C.F.R. § 431.50; (3) denied North Carolina Medicaid beneficiaries timely dental care, in violation of 42 U.S.C. § 1396a(a)(8) and 42 C.F.R. § 435.930; (4) denied Medicaid beneficiaries a free choice of dental care providers, in violation of 42 U.S.C. § 1396a(a)(23) and 42 C.F.R. § 431.51; (5) denied Medicaid beneficiaries dental care that is compa- rable to the care available to non-Medicaid patients, in violation of 42 U.S.C. § 1396a(a)(10)(B) and 42 C.F.R. §§ 440.230, 440.240; and (6) denied Medicaid beneficiaries proper access to early screening and treatment services, in violation of 42 U.S.C. §§ 1396a(a)(10)(A), 1396a(a)(43), 1396d(a)(4)(B), 1396d(R), and 42 C.F.R. § 441.50 et seq .
For relief, the plaintiffs request (1) a judgment declaring that "the Defendants’ failure to insure the availability of dental services vio- lates Plaintiffs’ rights under the Social Security Act . . . and its imple- menting rules and regulations" and (2) an injunction requiring the defendants to "make needed dental services immediately available to Medicaid beneficiaries in their respective localities" and requiring the defendants "to comply with the Federal statutes, rules, and regula- tions" governing Medicaid programs.
The North Carolina officials filed a motion to dismiss the plain- tiffs’ complaint, asserting Eleventh Amendment immunity, a lack of standing, and the failure of the complaint to state a claim under 42 U.S.C. § 1983 upon which relief can be granted. From the district court’s order denying their motion, the North Carolina officials filed this interloсutory appeal, challenging the district court’s ruling deny- ing them Eleventh Amendment immunity. They also ask this court to exercise pendent appellate jurisdiction over the other rulings made by the district court.
II
The district court’s order denying State officials Eleventh Amend-
ment immunity is an immediately appealable order,
see Puerto Rico
Aquaduct & Sewer Auth. v. Metcalf & Eddy, Inc.
,
The
Ex Parte Young
exception to Eleventh Amendment immunity
is designed to preserve the constitutional structure established by the
Supremacy Clause. Thus, it allows private citizens, in proper cases,
to petition a federal court to enjoin State officials in their official
capacities from engaging in future conduct that would violate the
Constitution or a federal statute.
See Ex Parte Young
,
But "just because a private citizen’s federal suit seeks declaratory
injunctive relief against State officials does not mean that it must
automatically be allowed to proceed under an exception to the Elev-
enth Amendment protection."
Bell Atlantic Md., Inc. v. MCI World-
Com, Inc.
,
Arguing that this case traverses the narrow limits of the Ex Parte Young exception in several respects, the North Carolina officials assert that the exception does not apply because: (1) this suit requires expenditures of money from North Carolina’s treasury and therefore the injunctive relief requested is not actually prospective; (2) the plaintiffs have not alleged an ongoing violation of federal law; (3) the law that plaintiffs allege has been violated is State law, not federal law; (4) the Medicaid Act was adopted under the Spending Clause and implemented through the voluntary participation of the States, making its prerequisites unenforceable under the Supremacy Clause — the fundamental reason for the Ex Parte Young exception; (5) the plaintiffs’ action is actually against the State and not against the indi- viduals and, in any event, violates the State’s special sovereignty interеsts; (6) application of the exception would alter the remedial scheme explicitly selected by Congress to enforce the Medicaid Act; and (7) the rights that plaintiffs seek to enforce are dis- cretionary in nature, not ministerial, and therefore are not subject to the Ex Parte Young exception.
We address, in turn, each of the reasons advanced by the North Carolina officials for not applying the Ex Parte Young exception to Eleventh Amendment immunity.
A
The North Carolina officials contend first that this action does not fall within the exception because the type of relief sought is, at its core, not truly prospective. They assert that, while the plaintiffs phrase their request in terms of prospective injunctive relief, they actually seek an order directing the State to raise the Medicaid reimbursement rates paid to participating dentists, thereby adversely affecting the State’s treasury. In response, plaintiffs point out that, although raising rates may be a method for inducing more dentists to participate in the Medicaid program, the plaintiffs’ complaint does not demand a particular methodology. Rather, it simply "requests injunc- tive relief to require the state officials to take steps to comply with a number of separate and varied Medicaid provisions."
We believe that the issue, as framed by the parties’ positions, does
not properly focus on the relevant question. It is true, as both parties
acknowledge, that, as an exception to Eleventh Amendment immu-
nity,
Ex Parte Young
actions must seek only prospective injunctive
relief. But simply because the implementation of such prospective
relief would require the expenditure of substantial sums of money
does not remove a claim from the exception.
Ex
Parte Young
"permits federal courts to enjoin state officials to con-
form their conduct to requirements of federal law, notwithstanding a
direct and substantial impact on the state treasury."
Milliken v. Brad-
ley
,
This distinction comes from the Supreme Court’s holdings in
Edel-
man
and
Milliken
. In
Edelman
, the Supreme Court determined that the
relief sought infringed on sovereign immunity under the Eleventh
Amendment because the plaintiffs sought a
retroactive
payment of
benefits that were found to have been wrongfully withheld from
proper recipients.
We conclude that the relief sought in this case is prospective in nature and, therefore, is of the type that falls within the Ex Parte Young exception. The plaintiffs requested an injunction mandating that in the future, State officials bring the North Carolina Medicaid program into compliance with the Medicaid Act. This mandate might potentially impact the State treasury, but it is nonetheless prospective.
B
The North Carolina officials next contend that plaintiffs’ suit has failed to allege an ongoing or continuing violation of federal law, as is necessary tо invoke the exception. These officials maintain that "[e]ach plaintiff, according to the complaint, is currently a Medicaid recipient who is receiving dental treatment by a dentist or clinic that accepts Medicaid patients at the current Medicaid reim- bursement rate" and that, therefore, even though violations may have occurred in the past, they are not ongoing.
While the North Carolina officials correctly note that the Ex Parte Young exception requires the allegation of an ongoing violation of federal law, see Idaho v. Coeur d’Alene Tribe , 521 U.S. 261, 281 (1997), their argument misreads the substance of the plaintiffs’ com- plaint. The plaintiffs do not rest their complaint on any claim that they have been еntirely unable to find dentists in North Carolina who will accept Medicaid reimbursement or that they have not received some treatment. Rather, they claim that North Carolina has failed, and con- tinues to fail, to operate a Medicaid program under which beneficia- ries can "obtain prompt and adequate dental services" on an ongoing basis, as would be available to the general population. They allege that because a large proportion of dentists do not participate in the Medicaid program, beneficiaries, such as themselves, have to travel long distances to find Mediсaid-participating dentists. If true, these claims allege ongoing violations of: 42 U.S.C. § 1396a(a)(30)(A), requiring States to "provide such methods and procedures relating to the utilization of, and the payment for, care and services available under the plan as . . . are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area" (emphasis added); and 42 U.S.C. § 1396a(a)(8), requiring States to "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 " (emphasis added). We thus conclude that the plaintiffs’ complaint is not defective for failing to allege ongoing violations of federal law.
C
In the same vein, the North Carolina officials assert that this action
seeks to enforce
State
law, not
federal
law. They contend that this
action seeks to challenge the State’s participation in the Medicaid pro-
gram and not to vindicate the supremacy of federal law, arguing that
"[m]erely because a State enacts a program that complies with federal
guidelines or requirements, the program’s requirements do not
thereby become or constitute federal law for purposes of
Ex Parte
Young
." For support, the North Carolina officials rely on our decision
in
Bragg
,
Again, the North Carolina officials correctly observe that the
Ex
Parte Young
exception does not apply to actions against State offi-
cials seeking to compel their complianсe with
State
law.
See Penn-
hurst State Sch. & Hosp. v. Haldeman
,
But the Medicaid Act is not analogous to the Surface Mining Act. It does not grant to the States exclusive jurisdiction over their Medic- aid programs. Rather, it requires States to have their plans approved by the supervising federal agency and to adhere to strict federal guidelines. 42 U.S.C. §§ 1396, 1396a. States that do not maintain their plans in compliance with the federal guidelines are denied con- tinuing Medicaid funding from the federal government. 42 U.S.C. § 1396c. Thus, these federal standards remain the directly applicable standards with which the States must comply in order to receive fed- eral Medicaid funding. Because the plaintiffs are seeking to enforce these directly applicable federal standards, the principles of Pennhurst and Bragg do not apply to remove this action from the Ex Parte Young exception.
D
The North Carolina officials next contend that the Medicaid Act,
as Spending Clause legislation, is not "supreme" law and therefore
does not fall within ’s defining purpose, which is to
"give life to the Supremacy Clause."
Bragg
,
The North Carolina officials’ novel position is, however, at odds
with existing, binding precedent. The Supreme Court has noted that,
"[a]lthough participation in the Medicaid program is entirely optional,
once a State elects to participate, it must comply with the require-
ments of Title XIX [the Medicaid Act]."
Harris v. McRae
, 448 U.S.
297, 301 (1980). Thus, for those States that opt to participate in the
program, the requirements of the Medicaid Act are mandatory. Con-
sistent with this conclusion, the Supreme Court has treated the Medic-
aid Act as "supreme" law and has invalidated conflicting State law
under the Supremacy Clause.
See Dalton v. Little Rock Family Plan-
ning Servs.
,
We are constrained to follow these precedents and thus conclude that the plaintiffs properly alleged an ongoing violation of supreme federal law.
E
The North Carolina officials next contend that "[a]ny injunctive relief ordered against the official defendants in this case would actu- ally be directed at North Carolina, something clearly forbidden by the Eleventh Amendment," and that the State is, therefore, the "real party in interest."
This assertion, however, applies to every Ex Parte Young action. Injunctive relief of the type sought in this case will almost always, in some sense, affect the State itself. See Coeur d’Alene Tribe , 521 U.S. at 269 (noting that "[w]hen suit is commenced against state officials, even if they are named and served as individuals, the State itself will have a continuing interest in the litigation whenever state policies or procedures are at stake. This commonsense observation of the State’s real interest when its officers are named as individuals has not escaped notice or comment from this Court, either before or after Young "). In fact, in itself, the actual defendаnt was the State Attorney General; yet the effect of the case was to nullify a State statute because the Court ordered the Attorney General not to enforce the statute. See generally 209 U.S. 123.
Similarly, in this case, even though the actual defendants are the State officials who oversee North Carolina’s Medicaid program, the relief requested would necessarily require North Carolina itself to change its Medicaid program to come into compliance with the Med- icaid Act. While such an order might result in an intrusion on North Carolina’s sovereignty, it would be precisely the type of order that is allowed under Ex Parte Young and its progeny. See Rehabilitation Ass’n of Va., Inc. v. Kozlowski , 42 F.3d 1444, 1449 (4th Cir. 1994) (rejecting Virginia’s claim that the State was the real party in interest because "[t]he suit [sought] prospective, injunctive relief only, rather than any form of retroactive compensatory damages, and [was] brought against Kozlowski, not the State").
As part of their argument that plaintiffs’ complaint is actually directed at the State, rather than at State officials, the North Carolina officials also contend that the plaintiffs’ requested relief would under- mine North Carolina’s "special sovereignty interests." They argue that North Carolina has a "special sovereignty interest in being able to decide the extent to which its limited Medicaid funds will be used for oрtional Medicaid services . . . or be spent to compensate dentists and other health care providers who choose to participate in Medicaid," and that an infringement on this interest makes the Ex Parte Young exception to Eleventh Amendment immunity inapplicable in this case.
In
Coeur d’Alene Tribe
, the Supreme Court recognized that in
some cases, special sovereignty interests will prevent an otherwise
proper
Ex Parte Young
action from proceeding against State officials.
The Court determined that
Ex Parte Young
did not apply in that case
because the suit "would divest the State of its sovereign control over
submerged lands, lands with a unique status in the law аnd infused
with a public trust the State itself is bound to respect."
Coeur d’Alene
Tribe
,
Similarly, we have recognized the applicability of the "special sov-
ereignty interest" exception in circumstances when quasi-judicial state
officers were sued in federal court to answer to assertions that they
made the wrong decision in deciding a matter within their jurisdic-
tion.
Bell Atlantic Md.
,
This case, however, does not present a special sovereignty interest that would allow North Carolina to use its sovereign immunity shield to avoid an otherwise proper action. Rather, it involves a federally designed healthcare program in which the federal government has invited the States to participate if they agree to cer- tain federally established conditions. "A state’s interest in administer- ing a welfare program at least partially funded by the federal government is not such a core sovereign interest as to preclude the application of ." J.B. ex rel. Hart v. Valdez , 186 F.3d 1280, 1287 (10th Cir. 1999); cf . TFWS, Inc. v. Schaefer , 242 F.3d 198, 205-06 (4th Cir. 2001) (holding that "Maryland’s power under the Twenty-first Amendment is not as basic or exclusive as a state’s territorial right to its submerged land," and concluding that the State’s power under that amendment does not qualify as a special State sov- ereignty interest under Coeur d’Alene Tribe ). North Carolina elected to participate in the federal Medicaid program and, therefore, to be bound by the requirements of the Medicaid Act. In doing so, the State agreed to the conditions of participation, including the possibility that if it failed to conform to the program as established by federal law, it faced the risk of being ordered by a federal court to correct the problems in its system. If the State did not want to face this federal involvement, it was free to decline federal funds and operate a State program for medical assistance using its own standards or to decline to operate such a program at all.
Although North Carolina may retain a special sovereignty interest in choosing whether to participate in the Medicaid program, once it elects to participate, it is not entitled to assert that interest to insulate itself from the requirements of the federal program.
F
The North Carolina officials next contend that in enacting the Med-
icaid Act, Congress provided а remedy that should displace any
Ex
Parte Young
action that seeks to compel State compliance with the
Medicaid Act. They note that under the Medicaid Act, withholding
federal funds is the statutory sanction for noncompliance.
It is true that in
Seminole Tribe of Florida v. Florida
,
Accordingly, we find no merit in this argument.
G
Finally, the North Carolina officials argue that this action is not a proper action because it involves discretionary, not ministerial, acts by State officials. See Ex Parte Young , 209 U.S. at 158 ("There is no doubt that the court cannot control the exercise of the discretion of an officer. It can only direct affirmative action where the officer having some duty to perform not involving discretion, but merely ministerial in its nature, refuses or neglects to take such action").
This argument lacks merit because the Medicaid Act does not pro- vide participating States with discretion to deny dental screening and treatment as specified in the Act. To the contrary, the Medicaid Act clearly mandates that a State provide a certain level and quality of dental care. In light of this duty, a federal court can "direct [the] affir- mative action [of complying with this duty]," and plaintiffs’ allеga- tions, if true, demonstrate that North Carolina State officers have "refuse[d] or neglect[ed] to take such action." Id. at 158; see also Lewis v. N.M. Dep’t of Health , 261 F.3d 970, 976 (10th Cir. 2001) (allowing an Ex Parte Young challenge to New Mexico’s Medicaid program to proceed despite an assertion that the claim impacted dis- cretionary acts by State officials because the action requested only an order that State officials "comply with federal law," not how to use their discretion in complying).
In this case the plaintiffs seek only an order requiring North Caro- lina officials to comply with the mandates of the Medicaid Act to pro- vide a specified type and level of care, not how to exercise any discretion conferred by that Act.
III
For the foregoing reasons, we affirm the district court’s order deny- ing the North Carolina officials’ motion to dismiss this case on the basis of Eleventh Amendment immunity. We conclude, as did the dis- trict court, that this action, as defined by the complaint, falls within the exception to that immunity provided by .
We decline to consider the other jurisdictional questions raised by
the defendants at this stage of the proceedings. These issues are not
"inextricably intertwined" with North Carolina’s Eleventh Amend-
ment immunity claim, nor is consideration of these issues "necessary
to ensure meaningful review of the . . . immunity question."
Taylor
v. Waters
,
AFFIRMED