Armstrong v. Exceptional Child Center, Inc. (2015)

(Slip Opinion)
OCTOBER TERM, 2014
Syllabus
NOTE: Where it is feasible, a syllabus (headnote) will be released, as is
being done in connection with this case, at the time the opinion is issued.
The syllabus constitutes no part of the opinion of the Court but has been
prepared by the Reporter of Decisions for the convenience of the reader.
See United States v. Detroit Timber & Lumber Co., 200 U. S. 321, 337.
SUPREME COURT OF THE UNITED STATES

Syllabus
ARMSTRONG ET AL. v. EXCEPTIONAL CHILD
CENTER, INC., ET AL.
CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR

THE NINTH CIRCUIT
No. 1415. Argued January 20, 2015Decided March 31, 2015
Providers of habilitation services under Idahos Medicaid plan are
reimbursed by the States Department of Health and Welfare. Section 30(A) of the Medicaid Act requires Idahos plan to assure that
payments are consistent with efficiency, economy, and quality of
care while safeguard[ing] against unnecessary utilization of . . .
care and services. 42 U. S. C. 1396a(a)(30)(A). Respondents, providers of habilitation services, sued petitioners, Idaho Health and
Welfare Department officials, claiming that Idaho reimbursed them
at rates lower than 30(A) permits, and seeking to enjoin petitioners
to increase these rates. The District Court entered summary judgment for the providers. The Ninth Circuit affirmed, concluding that
the Supremacy Clause gave the providers an implied right of action,
and that they could sue under this implied right of action to seek an
injunction requiring Idaho to comply with 30(a).
Held: The judgment is reversed.
567 Fed. Appx. 496, reversed.
JUSTICE SCALIA delivered the opinion of the Court, except as to Part
IV, concluding that the Supremacy Clause does not confer a private
right of action, and that Medicaid providers cannot sue for an injunction requiring compliance with 30(a). Pp. 310.
(a) The Supremacy Clause instructs courts to give federal law priority when state and federal law clash. Gibbons v. Ogden, 9 Wheat.
1, 210. But it is not the source of any federal rights, Golden State
Transit Corp. v. Los Angeles, 493 U. S. 103, 107, and certainly does
not create a cause of action. Nothing in the Clauses text suggests
otherwise, and nothing suggests it was ever understood as conferring
ARMSTRONG v. EXCEPTIONAL CHILD CENTER, INC.

Syllabus
a private right of action. Article I vests Congress with broad discretion over the manner of implementing its enumerated powers. Art I.,
8; McCulloch v. Maryland, 4 Wheat. 316, 421. It is unlikely that the
Constitution gave Congress broad discretion with regard to the enactment of laws, while simultaneously limiting Congresss power over
the manner of their implementation, making it impossible to leave
the enforcement of federal law to federal actors. Pp. 35.
(b) Reading the Supremacy Clause not to confer a private right of
action is consistent with this Courts preemption jurisprudence. The
ability to sue to enjoin unconstitutional actions by state and federal
officers is the creation of courts of equity, and reflects a long history
of judicial review of illegal executive action, tracing back to England.
This Court has never held nor suggested that this judge-made remedy, in its application to state officers, rests upon an implied right of
action contained in the Supremacy Clause. Pp. 56.
(c) Respondents suit cannot proceed in equity. The power of federal courts of equity to enjoin unlawful executive action is subject to
express and implied statutory limitations. See, e.g., Seminole Tribe
of Fla. v. Florida, 517 U. S. 44, 74. Here, the express provision of a
single remedy for a States failure to comply with Medicaids requirementsthe withholding of Medicaid funds by the Secretary of
Health and Human Services, 42 U. S. C. 1396cand the sheer complexity associated with enforcing 30(A) combine to establish Congresss intent to foreclose equitable relief, Verizon Md. Inc. v. Public
Serv. Commn of Md., 535 U. S. 635, 647. Pp. 610.
SCALIA, J., delivered the opinion of the Court with respect to Parts I,
II, and III, in which ROBERTS, C. J., and THOMAS, BREYER, and ALITO,
JJ., joined, and an opinion with respect to Part IV, in which ROBERTS,
C. J., and THOMAS and ALITO, JJ., joined. BREYER, J., filed an opinion
concurring in part and concurring in the judgment. SOTOMAYOR, J.,
filed a dissenting opinion, in which KENNEDY, GINSBURG, and KAGAN,
JJ., joined.
Cite as: 575 U. S. ____ (2015)
Opinion of the Court

NOTICE: This opinion is subject to formal revision before publication in the
preliminary print of the United States Reports. Readers are requested to
notify the Reporter of Decisions, Supreme Court of the United States, Washington, D. C. 20543, of any typographical or other formal errors, in order
that corrections may be made before the preliminary print goes to press.

_________________
No. 1415
_________________
RICHARD ARMSTRONG, ET AL., PETITIONERS v.
EXCEPTIONAL CHILD CENTER, INC., ET AL.
ON WRIT OF CERTIORARI TO THE UNITED STATES COURT OF
APPEALS FOR THE NINTH CIRCUIT
[March 31, 2015]
JUSTICE SCALIA delivered the opinion of the Court,

except as to Part IV.
We consider whether Medicaid providers can sue to
enforce (30)(A) of the Medicaid Act. 81 Stat. 911 (codified
as amended at 42 U. S. C. 1396a(a)(30)(A)).
I
Medicaid is a federal program that subsidizes the
States provision of medical services to 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. 13961. Like
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.
In order to qualify for Medicaid funding, the State of
Idaho adopted, and the Federal Government approved, a
Medicaid plan, 1396a(a), which Idaho administers
through its Department of Health and Welfare. Idahos
plan includes habilitation servicesin-home care for
individuals who, but for the provision of such services . . .

would require the level of care provided in a hospital or a

nursing facility or intermediate care facility for the mentally retarded the cost of which could be reimbursed under
the State plan, 1396n(c) and (c)(1). Providers of these
services are reimbursed by the Department of Health and
Welfare.
Section 30(A) of the Medicaid Act requires Idahos plan
to:
provide such methods and procedures relating to the
utilization of, and the payment for, care and services
available under the plan . . . as may be necessary to
safeguard against unnecessary utilization of such care
and services and to assure that payments are consistent with efficiency, economy, and quality of care
and 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 . . . .
42 U. S. C. 1396a(a)(30)(A).
Respondents are providers of habilitation services to
persons covered by Idahos Medicaid plan. They sued
petitionerstwo officials in Idahos Department of Health
and Welfarein the United States District Court for the
District of Idaho, claiming that Idaho violates 30(A) by
reimbursing providers of habilitation services at rates
lower than 30(A) permits. They asked the court to enjoin
petitioners to increase these rates.
The District Court entered summary judgment for the
providers, holding that Idaho had not set rates in a manner consistent with 30(A). Inclusion, Inc. v. Armstrong,
835 F. Supp. 2d 960 (2011). The Ninth Circuit affirmed.
567 Fed. Appx. 496 (2014). It said that the providers had
an implied right of action under the Supremacy Clause to
seek injunctive relief against the enforcement or implementation of state legislation. Id., at 497 (citing Inde-
Cite as: 575 U. S. ____ (2015)
pendent Living Center of Southern Cal. v. Shewry, 543

F. 3d 1050, 1065 (CA9 2008)). We granted certiorari. 573
U. S. ___ (2014).
II
The Supremacy Clause, Art. VI, cl. 2, reads:
This Constitution, and the Laws of the United
States which shall be made in Pursuance thereof; and
all Treaties made, or which shall be made, under the
Authority of the United States, shall be the supreme
Law of the Land; and the Judges in every State shall
be bound thereby, any Thing in the Constitution or
Laws of any State to the Contrary notwithstanding.
It is apparent that this Clause creates a rule of decision:
Courts shall regard the Constitution, and all laws
made in Pursuance thereof, as the supreme Law of the
Land. They must not give effect to state laws that conflict with federal laws. Gibbons v. Ogden, 9 Wheat. 1, 210
(1824). It is equally apparent that the Supremacy Clause
is not the source of any federal rights, Golden State
Transit Corp. v. Los Angeles, 493 U. S. 103, 107 (1989)
(quoting Chapman v. Houston Welfare Rights Organization, 441 U. S. 600, 613 (1979)), and certainly does not
create a cause of action. It instructs courts what to do
when state and federal law clash, but is silent regarding
who may enforce federal laws in court, and in what circumstances they may do so.
Hamilton wrote that the Supremacy Clause only declares a truth, which flows immediately and necessarily
from the institution of a Federal Government. The Federalist No. 33, p. 207 (J. Cooke ed. 1961). And Story described the Clause as a positive affirmance of that, which
is necessarily implied. 3 Commentaries on the Constitution of the United States 1831, p. 693 (1833). These
descriptions would have been grossly inapt if the Clause

were understood to give affected parties a constitutional

(and hence congressionally unalterable) right to enforce
federal laws against the States. And had it been understood to provide such significant private rights against the
States, one would expect to find that mentioned in the
preratification historical record, which contained ample
discussion of the Supremacy Clause by both supporters
and opponents of ratification. See C. Drahozal, The Supremacy Clause: A Reference Guide to the United States
Constitution 25 (2004); The Federalist No. 44, at 306 (J.
Madison). We are aware of no such mention, and respondents have not provided any. Its conspicuous absence
militates strongly against their position.
Additionally, it is important to read the Supremacy
Clause in the context of the Constitution as a whole.
Article I vests Congress with broad discretion over the
manner of implementing its enumerated powers, giving it
authority to make all Laws which shall be necessary and
proper for carrying [them] into Execution. Art. I, 8. We
have said that this confers upon the Legislature that
discretion, with respect to the means by which the powers
[the Constitution] confers are to be carried into execution,
which will enable that body to perform the high duties
assigned to it, McCulloch v. Maryland, 4 Wheat. 316, 421
(1819). It is unlikely that the Constitution gave Congress
such broad discretion with regard to the enactment of
laws, while simultaneously limiting Congresss power over
the manner of their implementation, making it impossible
to leave the enforcement of federal law to federal actors. If
the Supremacy Clause includes a private right of action,
then the Constitution requires Congress to permit the
enforcement of its laws by private actors, significantly
curtailing its ability to guide the implementation of federal law. It would be strange indeed to give a clause that
makes federal law supreme a reading that limits Congresss power to enforce that law, by imposing mandatory
Cite as: 575 U. S. ____ (2015)
private enforcementa limitation unheard-of with regard

to state legislatures.
To say that the Supremacy Clause does not confer a
right of action is not to diminish the significant role that
courts play in assuring the supremacy of federal law. For
once a case or controversy properly comes before a court,
judges are bound by federal law. Thus, a court may not
convict a criminal defendant of violating a state law that
federal law prohibits. See, e.g., Pennsylvania v. Nelson,
350 U. S. 497, 499, 509 (1956). Similarly, a court may not
hold a civil defendant liable under state law for conduct
federal law requires. See, e.g., Mutual Pharmaceutical Co.
v. Bartlett, 570 U. S. ___, ______ (2013) (slip op., at 13
14). And, as we have long recognized, if an individual
claims federal law immunizes him from state regulation,
the court may issue an injunction upon finding the state
regulatory actions preempted. Ex parte Young, 209 U. S.
123, 155156 (1908).
Respondents contend that our preemption jurisprudencespecifically, the fact that we have regularly considered whether to enjoin the enforcement of state laws
that are alleged to violate federal lawdemonstrates that
the Supremacy Clause creates a cause of action for its
violation. They are incorrect. It is true enough that we
have long held that federal courts may in some circumstances grant injunctive relief against state officers who
are violating, or planning to violate, federal law. See, e.g.,
Osborn v. Bank of United States, 9 Wheat. 738, 838839,
844 (1824); Ex parte Young, supra, at 150151 (citing
Davis v. Gray, 16 Wall. 203, 220 (1873)). But that has
been true not only with respect to violations of federal law
by state officials, but also with respect to violations of
federal law by federal officials. See American School of
Magnetic Healing v. McAnnulty, 187 U. S. 94, 110 (1902);
see generally L. Jaffe, Judicial Control of Administrative
Action 152196 (1965). Thus, the Supremacy Clause need

not be (and in light of our textual analysis above, cannot

be) the explanation. What our cases demonstrate is that,
in a proper case, relief may be given in a court of equity
. . . to prevent an injurious act by a public officer. Carroll
v. Safford, 3 How. 441, 463 (1845).
The ability to sue to enjoin unconstitutional actions by
state and federal officers is the creation of courts of equity,
and reflects a long history of judicial review of illegal
executive action, tracing back to England. See Jaffe &
Henderson, Judicial Review and the Rule of Law: Historical Origins, 72 L. Q. Rev. 345 (1956). It is a judge-made
remedy, and we have never held or even suggested that, in
its application to state officers, it rests upon an implied
right of action contained in the Supremacy Clause. That
is because, as even the dissent implicitly acknowledges,
post, at 4 (opinion of SOTOMAYOR, J.) it does not. The
Ninth Circuit erred in holding otherwise.
III
We turn next to respondents contention that, quite

apart from any cause of action conferred by the Supremacy Clause, this suit can proceed against Idaho in equity.
The power of federal courts of equity to enjoin unlawful
executive action is subject to express and implied statutory limitations. See, e.g., Seminole Tribe of Fla. v. Florida, 517 U. S. 44, 74 (1996). Courts of equity can no more
disregard statutory and constitutional requirements and
provisions than can courts of law. INS v. Pangilinan,
486 U. S. 875, 883 (1988) (quoting Hedges v. Dixon
County, 150 U. S. 182, 192 (1893); brackets omitted). In
our view the Medicaid Act implicitly precludes private
enforcement of 30(A), and respondents cannot, by invoking our equitable powers, circumvent Congresss exclusion
of private enforcement. See Douglas v. Independent Living Center of Southern Cal., Inc., 565 U. S. ___, ______
Cite as: 575 U. S. ____ (2015)
(2012) (ROBERTS, C. J., dissenting) (slip op., at 45).

Two aspects of 30(A) establish Congresss intent to
foreclose equitable relief. Verizon Md. Inc. v. Public Serv.
Commn of Md., 535 U. S. 635, 647 (2002). First, the sole
remedy Congress provided for a States failure to comply
with Medicaids requirementsfor the States breach of
the Spending Clause contractis the withholding of Medicaid funds by the Secretary of Health and Human Services. 42 U. S. C. 1396c. As we have elsewhere explained, the express provision of one method of enforcing
a substantive rule suggests that Congress intended to
preclude others. Alexander v. Sandoval, 532 U. S. 275,
290 (2001).
The provision for the Secretarys enforcement by withholding funds might not, by itself, preclude the availability
of equitable relief. See Virginia Office for Protection and
Advocacy v. Stewart, 563 U. S. 247, ______, n. 3 (2011)
(slip op., at 78, n. 3). But it does so when combined with
the judicially unadministrable nature of 30(A)s text. It
is difficult to imagine a requirement broader and less
specific than 30(A)s mandate that state plans provide for
payments that are consistent with efficiency, economy,
and quality of care, all the while safeguard[ing] against
unnecessary utilization of . . . care and services. Explicitly
conferring enforcement of this judgment-laden standard
upon the Secretary alone establishes, we think, that Congress wanted to make the agency remedy that it provided
exclusive, thereby achieving the expertise, uniformity,
widespread consultation, and resulting administrative
guidance that can accompany agency decisionmaking,
and avoiding the comparative risk of inconsistent interpretations and misincentives that can arise out of an
occasional inappropriate application of the statute in a
private action. Gonzaga Univ. v. Doe, 536 U. S. 273, 292
(2002) (BREYER, J., concurring in judgment). The sheer
complexity associated with enforcing 30(A), coupled with

the express provision of an administrative remedy, 1396c,

shows that the Medicaid Act precludes private enforcement of 30(A) in the courts.
B
The dissent agrees with us that the Supremacy Clause
does not provide an implied right of action, and that Congress may displace the equitable relief that is traditionally
available to enforce federal law. It disagrees only with our
conclusion that such displacement has occurred here.
The dissent insists that, because Congress is undoubtedly aware of the federal courts long-established practice
of enjoining preempted state action, it should generally be
presumed to contemplate such enforcement unless it
affirmatively manifests a contrary intent. Post, at 4
(emphasis added). But a long-established practice does
not justify a rule that denies statutory text its fairest
reading. Section 30(A), fairly read in the context of the
Medicaid Act, display[s] a[n] intent to foreclose the
availability of equitable relief. Verizon, supra, at 647. We
have no warrant to revise Congresss scheme simply because it did not affirmatively preclude the availability of
a judge-made action at equity. See Seminole Tribe, supra,
at 75 (inferring, in the absence of an affirmative statement by Congress, that equitable relief was unavailable).
Equally unavailing is the dissents reliance on 30(A)s
history. Section 30(A) was amended, on December 19,
1989, to include what the dissent calls the equal access
mandate, post, at 9the requirement that reimbursement rates be 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. 6402(a), 103
Stat. 2260. There existed at the time another provision,
known as the Boren Amendment, that likewise imposed
broad requirements on state Medicaid plans. 42 U. S. C.
Cite as: 575 U. S. ____ (2015)
1396a(a)(13)(A) (1982 ed., Supp. V). Lower courts had

interpreted the Boren Amendment to be privately enforceable under 1983. From this, the dissent infers that, when
Congress amended 30(A), it could not have failed to
anticipate that 30(A)s broad languageor at least that
of the equal access mandatewould be interpreted as
enforceable in a private action. Thus, concludes the dissent, Congresss failure to expressly preclude the private
enforcement of 30(A) suggests it intended not to preclude
private enforcement. Post, at 10.
This argument appears to rely on the prior-construction
canon; the rule that, when judicial interpretations have
settled the meaning of an existing statutory provision,
repetition of the same language in a new statute is presumed to incorporate that interpretation. Bragdon v.
Abbott, 524 U. S. 624, 645 (1998). But that canon has no
application here. The language of the two provisions is
nowhere near identical; and even if it had been, the question whether the Boren Amendment permitted private
actions was far from settled. When Congress amended
30(A) in 1989, this Court had already granted certiorari
to decide, but had not yet decided, whether the Boren
Amendment could be enforced through a 1983 suit. See
Baliles v. Virginia Hospital Assn., 493 U. S. 808 (Oct. 2,
1989) (granting certiorari). Our decision permitting a
1983 action did not issue until June 14, 1990almost six
months after the amendment to 30(A). Wilder v. Virginia
Hospital Assn., 496 U. S. 498.* The existence of a granted
petition for certiorari demonstrates quite clearly that the
* Respondents do not claim that Wilder establishes precedent for a

private cause of action in this case. They do not assert a 1983 action,
since our later opinions plainly repudiate the ready implication of a
1983 action that Wilder exemplified. See Gonzaga, Univ. v. Due, 536
U. S. 273, 283 (2002) (expressly reject[ing] the notion, implicit in
Wilder, that our cases permit anything short of an unambiguously
conferred right to support a cause of action brought under 1983).
10

the
Court
CALIA
, J.
Opinion of S
question whether the Boren Amendment could be privately enforced was unsettled at the time of 30(A)s 1989
amendmentso that if Congress was aware of the parallel
(which is highly doubtful) the course that awareness
would have prompted (if any) would not have been legislative silence but rather express specification of the availability of private enforcement (if that was what Congress
intended).
Finally, the dissent speaks as though we leave these
plaintiffs with no resort. That is not the case. Their relief
must be sought initially through the Secretary rather than
through the courts. The dissents complaint that the
sanction available to the Secretary (the cut-off of funding)
is too massive to be a realistic source of relief seems to us
mistaken. We doubt that the Secretarys notice to a
State that its compensation scheme is inadequate will be
ignored.
IV
The last possible source of a cause of action for respondents is the Medicaid Act itself. They do not claim that,
and rightly so. Section 30(A) lacks the sort of rightscreating language needed to imply a private right of action. Sandoval, supra at 286287. It is phrased as a
directive to the federal agency charged with approving
state Medicaid plans, not as a conferral of the right to sue
upon the beneficiaries of the States decision to participate
in Medicaid. The Act says that the Secretary shall approve any plan which fulfills the conditions specified in
subsection (a), the subsection that includes 30(A). 42
U. S. C. 1396a(b). We have held that such language
reveals no congressional intent to create a private right of
action. Sandoval, supra at 289; see also Universities
Research Assn., Inc. v. Coutu, 450 U. S. 754, 772 (1981).
And again, the explicitly conferred means of enforcing
compliance with 30(A) by the Secretarys withholding
Cite as: 575 U. S. ____ (2015)
11
the
Court
CALIA
, J.
Opinion of S
funding, 1396c, suggests that other means of enforcement

are precluded, Sandoval, supra, at 290.
Spending Clause legislation like Medicaid is much in
the nature of a contract. Pennhurst State School and
Hospital v. Halderman, 451 U. S. 1, 17 (1981). The notion
that respondents have a right to sue derives, perhaps,
from the fact that they are beneficiaries of the federalstate Medicaid agreement, and that intended beneficiaries, in modern times at least, can sue to enforce the obligations of private contracting parties. See 13 R. Lord,
Williston on Contracts 37:1237.13, pp. 123135 (4th ed.
2013). We doubt, to begin with, that providers are intended
beneficiaries (as opposed to mere incidental beneficiaries) of the Medicaid agreement, which was concluded for
the benefit of the infirm whom the providers were to serve,
rather than for the benefit of the providers themselves.
See Pharmaceutical Research and Mfrs. of America v.
Walsh, 538 U. S. 644, 683 (2003) (THOMAS, J., concurring
in judgment). More fundamentally, however, the modern
jurisprudence permitting intended beneficiaries to sue
does not generally apply to contracts between a private
party and the government, Astra USA, Inc. v. Santa Clara
County, 563 U. S. ___, ___ (2011) (slip op., at 6); see Williston, supra, at 37:3537:36, at 256271; 9 J. Murray,
Corbin on Contracts 45.6, p. 92 (rev. ed. 2007)much
less to contracts between two governments. Our precedents establish that a private right of action under federal
law is not created by mere implication, but must be unambiguously conferred, Gonzaga, 536 U. S., at 283.
Nothing in the Medicaid Act suggests that Congress
meant to change that for the commitments made under
30(A).
*
*
*
The judgment of the Ninth Circuit Court of Appeals is
reversed.
It is so ordered.
Cite as: 575 U. S. ____ (2015)
Opinion of BREYER, J.

_________________
No. 1415
_________________
[March 31, 2015]
JUSTICE BREYER, concurring in part and concurring in

the judgment.
I join Parts I, II, and III of the Courts opinion.
Like all other Members of the Court, I would not characterize the question before us in terms of a Supremacy
Clause cause of action. Rather, I would ask whether
federal courts may in [these] circumstances grant injunctive relief against state officers who are violating, or planning to violate, federal law. Ante, at 5; post, at 4
(SOTOMAYOR, J., dissenting). I believe the answer to this
question is no.
That answer does not follow from the application of a
simple, fixed legal formula separating federal statutes
that may underlie this kind of injunctive action from those
that may not. [T]he statute books are too many, the laws
too diverse, and their purposes too complex, for any single
legal formula to offer courts more than general guidance. Gonzaga Univ. v. Doe, 536 U. S. 273, 291 (2012)
(BREYER, J., concurring in judgment). Rather, I believe
that several characteristics of the federal statute before
us, when taken together, make clear that Congress intended to foreclose respondents from bringing this particular action for injunctive relief.
For one thing, as the majority points out, 30(A) of the
Medicaid Act, 42 U. S. C. 1396a(a)(30)(A), sets forth a

federal mandate that is broad and nonspecific. See ante,

at 7. But, more than that, 30(A) applies its broad standards to the setting of rates. The history of ratemaking
demonstrates that administrative agencies are far better
suited to this task than judges. More than a century ago,
Congress created the Interstate Commerce Commission,
the first great federal regulatory rate-setting agency, and
endowed it with authority to set reasonable railroad
rates. Ch. 104, 24 Stat. 379 (1887). It did so in part because judicial efforts to maintain reasonable rate levels
had proved inadequate. See I. Sharfman, Railway Regulation: An Analysis of the Underlying Problems in Railway
Economics from the Standpoint of Government Regulation
4344 (1915).
Reading 30(A) underscores the complexity and nonjudicial nature of the rate-setting task. That provision
requires State Medicaid plans to assure that payments
are consistent with efficiency, economy, and quality of care
and are sufficient to enlist enough providers to assure
care and services equivalent to that available to the
general population in the geographic area. 1396a(a)
(30)(A). The methods that a state agency, such as Idahos
Department of Health and Welfare, uses to make this kind
of determination may involve subsidiary determinations
of, for example, the actual cost of providing quality services, including personnel and total operating expenses;
changes in public expectations with respect to delivery of
services; inflation; a comparison of rates paid in neighboring States for comparable services; and a comparison of
any rates paid for comparable services in other public or
private capacities. See App. to Reply to Brief in Opposition 16; Idaho Code Ann. 56118 (2012).
At the same time, 30(A) applies broadly, covering
reimbursements provided to approximately 1.36 million
doctors, serving over 69 million patients across the Nation.
See Dept. of Health and Human Servs., Office of Inspector
Cite as: 575 U. S. ____ (2015)
General, Access to Care: Provider Availability in Medicaid

Managed Care 1, 5 (Dec. 2014). And States engage in
time-consuming efforts to obtain public input on proposed
plan amendments. See, e.g., Kansas Medicaid: Design and
Implementation of a Public Input and Stakeholder Consult Process (Sept. 16, 2011) (prepared by Deloitte Consulting, LLP) (describing public input on Kansas proposed
Medicaid amendments).
I recognize that federal courts have long become accustomed to reviewing for reasonableness or constitutionality
the rate-setting determinations made by agencies. See 5
U. S. C. 706; FPC v. Hope Natural Gas Co., 320 U. S. 591,
602606 (1944). But this is not such an action. Instead,
the lower courts here, relying on the rate-setting standard
articulated in Orthopaedic Hospital v. Belshe, 103 F. 3d
1491 (CA9 1997), required the State to set rates that
approximate the cost of quality care provided efficiently
and economically. Id., at 1496. See Inclusion, Inc. v.
Armstrong, 835 F. Supp. 2d 960, 963964 (Idaho 2011),
affd, 567 Fed. Appx. 496 (CA9 2014). To find in the law a
basis for courts to engage in such direct rate-setting could
set a precedent for allowing other similar actions, potentially resulting in rates set by federal judges (of whom
there are several hundred) outside the ordinary channel of
federal judicial review of agency decisionmaking. The
consequence, I fear, would be increased litigation, inconsistent results, and disorderly administration of highly
complex federal programs that demand public consultation, administrative guidance and coherence for their
success. I do not believe Congress intended to allow a
statute-based injunctive action that poses such risks (and
that has the other features I mention).
I recognize that courts might in particular instances be
able to resolve rate-related requests for injunctive relief
quite easily. But I see no easy way to separate in advance
the potentially simple sheep from the more harmful rate-

making goats. In any event, this case, I fear, belongs in

the latter category. See Belshe, supra, at 1496. Compare
Brief for Respondents 2, n. 1 (claiming that respondents
seek only to enforce federally approved methodology), with
Brief for United States as Amicus Curiae 5, n. 2 (the relevant methodology has not been approved). See also Idaho
Code Ann. 56118 (describing in general terms what
appears to be a complex rate-setting methodology, while
leaving unclear the extent to which Idaho is bound to use,
rather than merely consider, actual provider costs).
For another thing, like the majority, I would ask why, in
the complex rate-setting area, other forms of relief are
inadequate. If the Secretary of Health and Human Services concludes that a State is failing to follow legally
required federal rules, the Secretary can withhold federal
funds. See ante, at 7 (citing 42 U. S. C. 1396c). If withholding funds does not work, the federal agency may be
able to sue a State to compel compliance with federal
rules. See Tr. of Oral Arg. 23, 52 (Solicitor General and
respondents acknowledging that the Federal Government
might be able to sue a State to enjoin it from paying less
than what 30(A) requires). Cf., e.g., Arizona v. United
States, 567 U. S. __ (2012) (allowing similar action in
another context).
Moreover, why could respondents not ask the federal
agency to interpret its rules to respondents satisfaction, to
modify those rules, to promulgate new rules or to enforce
old ones? See 5 U. S. C. 553(e). Normally, when such
requests are denied, an injured party can seek judicial
review of the agencys refusal on the grounds that it is
arbitrary, capricious, an abuse of discretion, or otherwise
not in accordance with law. 702, 706(2)(A). And an
injured party can ask the court to compel agency action
unlawfully withheld or unreasonably delayed. 702,
706(1). See also Tr. of Oral Arg. 1516 (arguing that
providers can bring an action under the Administrative
Cite as: 575 U. S. ____ (2015)
Procedure Act (APA) whenever a waiver program is renewed or can seek new agency rulemaking); Japan Whaling Assn. v. American Cetacean Soc., 478 U. S. 221, 230,
n. 4, 231 (1986) (APA challenge to the Secretary of Commerces failure to act).
I recognize that the law may give the federal agency
broad discretionary authority to decide when and how to
exercise or to enforce statutes and rules. See Massachusetts v. EPA, 549 U. S. 497, 527 (2007). As a result, it may
be difficult for respondents to prevail on an APA claim
unless it stems from an agencys particularly egregious
failure to act. But, if that is so, it is because Congress
decided to vest broad discretion in the agency to interpret
and to enforce 30(A). I see no reason for this Court to
circumvent that congressional determination by allowing
this action to proceed.
Cite as: 575 U. S. ____ (2015)
SOTOMAYOR, J., dissenting

_________________
No. 1415
_________________
[March 31, 2015]
JUSTICE SOTOMAYOR, with whom JUSTICE KENNEDY,

JUSTICE GINSBURG, and JUSTICE KAGAN join, dissenting.
Suits in federal court to restrain state officials from
executing laws that assertedly conflict with the Constitution or with a federal statue are not novel. To the contrary,
this Court has adjudicated such requests for equitable
relief since the early days of the Republic. Nevertheless,
today the Court holds that Congress has foreclosed private
parties from invoking the equitable powers of the federal
courts to require States to comply with 30(A) of the Medicaid Act, 42 U. S. C. 1396a(a)(30)(A). It does so without
pointing to the sort of detailed remedial scheme we have
previously deemed necessary to establish congressional
intent to preclude resort to equity. Instead, the Court
relies on Congress provision for agency enforcement of
30(A)an enforcement mechanism of the sort we have
already definitively determined not to foreclose private
actionsand on the mere fact that 30(A) contains relatively broad language. As I cannot agree that these statutory provisions demonstrate the requisite congressional
intent to restrict the equitable authority of the federal
courts, I respectfully dissent.

That parties may call upon the federal courts to enjoin

unconstitutional government action is not subject to serious dispute. Perhaps the most famous exposition of this
principle is our decision in Ex parte Young, 209 U. S. 123
(1908), from which the doctrine derives its usual name.
There, we held that the shareholders of a railroad could
seek an injunction preventing the Minnesota attorney
general from enforcing a state law setting maximum
railroad rates because the Eleventh Amendment did not
provide the officials with immunity from such an action
and the federal court had the power in equity to grant a
temporary injunction. Id., at 148. This Court had earlier
recognized similar equitable authority in Osborn v. Bank
of United States, 9 Wheat. 738 (1824), in which a federal
court issued an injunction prohibiting an Ohio official from
executing a state law taxing the Bank of the United
States. Id., at 838839. We affirmed in relevant part,
concluding that the case was cognizable in a Court of
equity, and holding it to be proper to grant equitable
relief insofar as the state tax was repugnant to the
federal law creating the national bank. Id., at 839, 859.
More recently, we confirmed the vitality of this doctrine in
Free Enterprise Fund v. Public Company Accounting
Oversight Bd., 561 U. S. 477 (2010). There, we found no
support for the argument that a challenge to governmental action under the Appointments Clause or separationof-powers principles should be treated differently than
every other constitutional claim for which equitable
relief has long been recognized as the proper means for
preventing entities from acting unconstitutionally. Id.,
at 491, n. 2.
A suit, like this one, that seeks relief against state
officials acting pursuant to a state law allegedly preempted
by a federal statute falls comfortably within this doc-
Cite as: 575 U. S. ____ (2015)
trine. A claim that a state law contravenes a federal

statute is basically constitutional in nature, deriving its
force from the operation of the Supremacy Clause, Douglas v. Seacoast Products, Inc., 431 U. S. 265, 271272
(1977), and the application of preempted state law is
therefore unconstitutional, Crosby v. National Foreign
Trade Council, 530 U. S. 363, 388 (2000); accord, e.g.,
McCulloch v. Maryland, 4 Wheat. 316, 436 (1819) (that
States have no power to enact laws interfering with the
operations of the constitutional laws enacted by Congress
is the unavoidable consequence of that supremacy which
the constitution has declared; such a state law is unconstitutional and void). We have thus long entertained
suits in which a party seeks prospective equitable protection from an injurious and preempted state law without
regard to whether the federal statute at issue itself provided a right to bring an action. See, e.g., Foster v. Love,
522 U. S. 67 (1997) (state election law that permitted the
winner of a state primary to be deemed the winner of
election to Congress held preempted by federal statute
setting date of congressional elections); Shaw v. Delta Air
Lines, Inc., 463 U. S. 85 (1983) (state law preempted in
part by the federal Employee Retirement Income Security
Act of 1974); Railroad Transfer Service, Inc. v. Chicago,
386 U. S. 351 (1967) (city ordinance imposing licensing
requirements on motor carrier transporting railroad passengers held preempted by federal Interstate Commerce
Act); Campbell v. Hussey, 368 U. S. 297 (1961) (state law
requiring labeling of certain strains of tobacco held
preempted by the federal Tobacco Inspection Act); Railway
Co. v. McShane, 22 Wall. 444 (1875) (state taxation of land
possessed by railroad company held invalid under federal
Act of July 2, 1864). Indeed, for this reason, we have
characterized the availability of prospective relief of the
sort awarded in Ex parte Young as giving life to the
Supremacy Clause. Green v. Mansour, 474 U. S. 64, 68

(1985).
Thus, even though the Court is correct that it is somewhat misleading to speak of an implied right of action
contained in the Supremacy Clause, ante, at 6, that does
not mean that parties may not enforce the Supremacy
Clause by bringing suit to enjoin preempted state action.
As the Court also recognizes, we have long held that
federal courts may in some circumstances grant injunctive
relief against state officers who are violating, or planning
to violate, federal law. Ante, at 5.
B
Most important for purposes of this case is not the mere
existence of this equitable authority, but the fact that it is
exceedingly well establishedsupported, as the Court
puts it, by a long history. Ante, at 6. Congress may, if it
so chooses, either expressly or implicitly preclude Ex parte
Young enforcement actions with respect to a particular
statute or category of lawsuit. See, e.g., 28 U. S. C. 1341
(prohibiting federal judicial restraints on the collection of
state taxes); Seminole Tribe of Fla. v. Florida, 517 U. S.
44, 7576 (1996) (comprehensive alternative remedial
scheme can establish Congress intent to foreclose Ex parte
Young actions). But because Congress is undoubtedly
aware of the federal courts long-established practice of
enjoining preempted state action, it should generally be
presumed to contemplate such enforcement unless it
affirmatively manifests a contrary intent. Unless a statute in so many words, or by a necessary and inescapable
inference, restricts the courts jurisdiction in equity, the
full scope of that jurisdiction is to be recognized and applied. Porter v. Warner Holding Co., 328 U. S. 395, 398
(1946).
In this respect, equitable preemption actions differ from
suits brought by plaintiffs invoking 42 U. S. C. 1983 or an
implied right of action to enforce a federal statute. Suits
Cite as: 575 U. S. ____ (2015)
for redress designed to halt or prevent the constitutional

violation rather than the award of money damages seek
traditional forms of relief. United States v. Stanley, 483
U. S. 669, 683 (1987). By contrast, a plaintiff invoking
1983 or an implied statutory cause of action may seek a
variety of remediesincluding damagesfrom a potentially broad range of parties. Rather than simply pointing
to background equitable principles authorizing the action
that Congress presumably has not overridden, such a
plaintiff must demonstrate specific congressional intent to
create a statutory right to these remedies. See Gonzaga
Univ. v. Doe, 536 U. S. 273, 290 (2002); Alexander v.
Sandoval, 532 U. S. 275, 286 (2001); see also Golden State
Transit Corp. v. Los Angeles, 493 U. S. 103, 114 (1989)
(KENNEDY, J., dissenting) (Because a preemption claim
does not seek to enforce a statutory right, [t]he injured
party does not need 1983 to vest in him a right to assert
that an attempted exercise of jurisdiction or control violates the proper distribution of powers within the federal
system). For these reasons, the principles that we have
developed to determine whether a statute creates an
implied right of action, or is enforceable through 1983,
are not transferable to the Ex parte Young context.
II
In concluding that Congress has implicitly preclude[d]
private enforcement of 30(A), ante, at 6, the Court ignores this critical distinction and threatens the vitality of
our Ex parte Young jurisprudence. The Court identifies
only a single prior decisionSeminole Tribein which we
have ever discerned such congressional intent to foreclose
equitable enforcement of a statutory mandate. Ante, at 6.
Even the most cursory review of that decision reveals how
far afield it is from this case.
In Seminole Tribe, the plaintiff Indian Tribe had invoked Ex parte Young in seeking to compel the State of

Florida to negotiate in good faith with [the] tribe toward

the formation of a compact governing certain gaming
activities, as required by a provision of the Indian Gaming
Regulatory Act, 25 U. S. C. 2710(d)(3). 517 U. S., at 47.
We rejected this effort, observing that Congress passed
2710(d)(3) in conjunction with the carefully crafted and
intricate remedial scheme set forth in 2710(d)(7). Id., at
7374. That latter provision allowed a tribe to sue for
violations of the duty to negotiate 180 days after requesting such negotiations, but specifically limited the remedy
that a court could grant to an order directing the State
and the Indian tribe to conclude a compact within 60
days, and provided that the only sanction for the violation
of such an order would be to require the parties to submit a proposed compact to a mediator. Id., at 74;
2710(d)(7)(B)(i), (iii), (iv). The statute further directed
that if the State should fail to abide by the mediators
selected compact, the sole remedy would be for the Secretary of the Interior, in consultation with the tribe, to
prescribe regulations governing gaming. See 517 U. S., at
7475; 2710(d)(7)(B)(vii). We concluded that Congress
must have intended this procedural route to be the exclusive means of enforcing 2710(d)(3). As we explained: If
2710(d)(3) could be enforced in a suit under Ex parte
Young, 2710(d)(7) would have been superfluous; it is
difficult to see why an Indian tribe would suffer through
the intricate scheme of 2710(d)(7) when more complete
and more immediate relief would be available under
Ex parte Young. 517 U. S., at 75.
What is the equivalent carefully crafted and intricate
remedial scheme for enforcement of 30(A)? The Court
relies on two aspects of the Medicaid Act, but, whether
considered separately or in combination, neither suffices.
First, the Court cites 42 U. S. C. 1396c, which authorizes the Secretary of Health and Human Services (HHS) to
withhold federal Medicaid payments to a State in whole or
Cite as: 575 U. S. ____ (2015)
in part if the Secretary determines that the State has

failed to comply with the obligations set out in 1396a,
including 30(A). See ante, at 78. But in striking contrast to the remedial provision set out in the Indian Gaming Regulatory Act, 1396c provides no specific procedure
that parties actually affected by a States violation of its
statutory obligations may invoke in lieu of Ex parte
Youngleaving them without any other avenue for seeking relief from the State. Nor will 1396c always provide a
particularly effective means for redressing a States violations: If the State has violated 30(A) by refusing to reimburse medical providers at a level sufficient to enlist
enough providers so that care and services are available
to Medicaid beneficiaries to the same extent as they are
available to the general population, agency action resulting in a reduced flow of federal funds to that State will
often be self-defeating. 1396a(30)(A); see Brief for Former HHS Officials as Amici Curiae 18 (noting that HHS is
often reluctant to initiate compliance actions because a
states non-compliance creates a damned-if-you-do,
damned-if-you-dont scenario where the withholding of
state funds will lead to depriving the poor of essential
medical assistance). Far from rendering 1396c superfluous, then, Ex parte Young actions would seem to be an
anticipated and possibly necessary supplement to this
limited agency-enforcement mechanism. Seminole Tribe,
517 U. S., at 75. Indeed, presumably for these reasons, we
recently rejected the very contention the Court now accepts, holding that [t]he fact that the Federal Government can exercise oversight of a federal spending program
and even withhold or withdraw funds . . . does not demonstrate that Congress has displayed an intent not to provide the more complete and more immediate relief that
would otherwise be available under Ex parte Young.
Virginia Office for Protection and Advocacy v. Stewart, 563
U. S. 247, ________, n. 3 (2011) (slip op., at 78, n. 3)

(internal quotation marks omitted).

Section 1396c also parallels other provisions scattered
throughout the Social Security Act that likewise authorize
the withholding of federal funds to States that fail to fulfill
their obligations. See, e.g., 609(a), 1204, 1354. Yet, we
have consistently authorized judicial enforcement of the
Act. See Maine v. Thiboutot, 448 U. S. 1, 6 (1980) (collecting cases). Rosado v. Wyman, 397 U. S. 397 (1970), provides a fitting illustration. There, we considered a provision of the Social Security Act mandating that, in
calculating benefits for participants in the Aid to Families
with Dependent Children Program, States make adjustments to reflect fully changes in living costs. Id., at
412 (quoting 602(a)(23) (1964 ed., Supp. IV)). We expressed no hesitation in concluding that federal courts
could require compliance with this obligation, explaining:
It is . . . peculiarly part of the duty of this tribunal, no
less in the welfare field than in other areas of the law, to
resolve disputes as to whether federal funds allocated to
the States are being expended in consonance with the
conditions that Congress has attached to their use. Id.,
at 422423. We so held notwithstanding the existence of
an enforcement provision permitting a federal agency to
make a total or partial cutoff of federal funds. See id., at
406, n. 8 (citing 1316).
Second, perhaps attempting to reconcile its treatment of
1396c (2012 ed.) with this longstanding precedent, the
Court focuses on the particular language of 30(A), contending that this provision, at least, is so judicially unadministrable that Congress must have intended to
preclude its enforcement in private suits. Ante, at 7.
Admittedly, the standard set out in 30(A) is fairly broad,
requiring that a state Medicaid plan:
provide such methods and procedures relating to the
utilization of, and the payment for, care and services
available under the plan . . . as may be necessary to
Cite as: 575 U. S. ____ (2015)
safeguard against unnecessary utilization of such care

and services and to assure that payments are consistent with efficiency, economy, and quality of care
and 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.
1396a(a)(30)(A).
But mere breadth of statutory language does not require
the Court to give up all hope of judicial enforcementor,
more important, to infer that Congress must have done so.
In fact, the contention that 30(A)s language was intended to foreclose private enforcement actions entirely is
difficult to square with the provisions history. The specific equal access mandate invoked by the plaintiffs in this
casethat reimbursement rates be 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 areawas added to 30(A) in 1989. 103 Stat.
2260. At that time, multiple Federal Courts of Appeals
had held that the so-called Boren Amendment to the
Medicaid Act was enforceable pursuant to 1983as we
soon thereafter concluded it was. See Wilder v. Virginia
Hospital Assn., 496 U. S. 498, 504505, 524 (1990). The
Boren Amendment employed language quite similar to
that used in 30(A), requiring that a state plan:
provide . . . for payment . . . of the hospital services,
nursing facility services, and services in an intermediate care facility for the mentally retarded provided
under the plan through the use of rates . . . which the
State finds, and makes assurances satisfactory to the
Secretary, are reasonable and adequate to meet the
costs which must be incurred by efficiently and economically operated facilities in order to provide care
10

and services in conformity with applicable State and

Federal laws, regulations, and quality and safety
standards and to assure that individuals eligible for
medical assistance have reasonable access . . . to inpatient hospital services of adequate quality.
1396a(a)(13)(A) (1982 ed., Supp. V).
It is hard to believe that the Congress that enacted the
operative version of 30(A) could have failed to anticipate
that it might be similarly enforceable. Even if, as the
Court observes, the question whether the Boren Amendment was enforceable under 1983 was unsettled at the
time, ante, at 10 (emphasis deleted), surely Congress
would have spoken with far more clarity had it actually
intended to preclude private enforcement of 30(A)
through not just 1983 but also Ex parte Young.
Of course, the broad scope of 30(A)s language is not
irrelevant. But rather than compelling the conclusion that
the provision is wholly unenforceable by private parties,
its breadth counsels in favor of interpreting 30(A) to
provide substantial leeway to States, so that only in rare
and extreme circumstances could a State actually be held
to violate its mandate. The provisions scope may also
often require a court to rely on HHS, which is comparatively expert in the statutes subject matter. Douglas v.
Independent Living Center of Southern Cal., Inc., 565 U. S
___, ___ (2012) (slip op., at 7). When the agency has made
a determination with respect to what legal standard
should apply, or the validity of a States procedures for
implementing its Medicaid plan, that determination
should be accorded the appropriate deference. See, e.g.,
Chevron U. S. A. Inc. v. Natural Resources Defense Council, Inc., 467 U. S. 837 (1984); Skidmore v. Swift & Co.,
323 U. S. 134 (1944). And if faced with a question that
presents a special demand for agency expertise, a court
might call for the views of the agency, or refer the question
Cite as: 575 U. S. ____ (2015)
11
to the agency under the doctrine of primary jurisdiction.

See Rosado, 397 U. S., at 406407; Pharmaceutical Research and Mfrs. of America v. Walsh, 538 U. S. 644, 673
(2003) (BREYER, J., concurring in part and concurring in
judgment). Finally, because the authority invoked for
enforcing 30(A) is equitable in nature, a plaintiff is not
entitled to relief as of right, but only in the sound discretion of the court. See Amoco Production Co. v. Gambell,
480 U. S. 531, 542 (1987). Given the courts ability to both
respect States legitimate choices and defer to the federal
agency when necessary, I see no basis for presuming that
Congress believed the Judiciary to be completely incapable
of enforcing 30(A).*
* That is not to say that the Court of Appeals in this case necessarily
applied 30(A) correctly. Indeed, there are good reasons to think the
court construed 30(A) to impose an overly stringent obligation on the
States. While the Ninth Circuit has understood 30(A) to compel
States to rely on responsible cost studies, and to reimburse for services at rates that approximate the cost of quality care provided
efficiently and economically, Orthopaedic Hospital v. Belshe, 103 F. 3d
1491, 1496 (1997), other courts have read 30(A) to require only that
rates be high enough to ensure that services are available to Medicaid
participants. See Pennsylvania Pharmacists Assn. v. Houstoun, 283
F. 3d 531, 538 (CA3 2002); Evergreen Presbyterian Ministries, Inc. v.
Hood, 235 F. 3d 908, 928929 (CA5 2000); Methodist Hospitals, Inc. v.
Sullivan, 91 F. 3d 1026, 1030 (CA7 1996). This Court declined to grant
certiorari to address whether the Ninth Circuits reading of 30(A) is
correct. See 573 U. S. ___ (2014). But JUSTICE BREYER, in his concurrence, appears to mistake that question about the merits of the Ninth
Circuits standard for the question this Court actually granted certiorari to addressthat is, whether 30 is judicially enforceable at all.
See ante, at 34 (opinion concurring in part and concurring in judgment). To answer that question, one need only recognize, as JUSTICE
BREYER does, that federal courts have long become accustomed to
reviewing for reasonableness or constitutionality the rate-setting
determinations made by agencies. Ante, at 3. A private party who
invokes the jurisdiction of the federal courts in order to enjoin a state
agencys implementation of rates that are so unreasonably low as to
violate 30(A) seeks a determination of exactly this sort.
12

*
*
*
In sum, far from identifying a carefully crafted . . .
remedial scheme demonstrating that Congress intended
to foreclose Ex parte Young enforcement of 30(A), Seminole Tribe, 517 U. S., at 7374, the Court points only to
two provisions.
The first is 1396c, an agencyenforcement provision that, given our precedent, cannot
preclude private actions. The second is 30(A) itself,
which, while perhaps broad, cannot be understood to manifest congressional intent to preclude judicial involvement.
The Courts error today has very real consequences.
Previously, a State that set reimbursement rates so low
that providers were unwilling to furnish a covered service
for those who need it could be compelled by those affected
to respect the obligation imposed by 30(A). Now, it must
suffice that a federal agency, with many programs to
oversee, has authority to address such violations through
the drastic and often counterproductive measure of withholding the funds that pay for such services. Because a
faithful application of our precedents would have led to a
contrary result, I respectfully dissent.

Armstrong v. Exceptional Child Center, Inc. (2015)

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Armstrong v. Exceptional Child Center, Inc. (2015)

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(Slip Opinion)

OCTOBER TERM, 2014

SUPREME COURT OF THE UNITED STATES

ARMSTRONG ET AL. v. EXCEPTIONAL CHILD

CENTER, INC., ET AL.

CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR