457 U.S. 991 (1982)
Congress established the Medicaid program in 1965 as Title XIX of the Social Security Act to provide federal financial assistance to States that choose to reimburse medical costs incurred by the poor.1
As a participating State, New York provides Medicaid assistance to eligible persons who receive care in private nursing homes, which are designated as either "skilled nursing facilities" (SNF's) or "health related facilities" (HRF's).2 Nursing homes chosen by Medicaid patients are directly reimbursed by the State for the reasonable cost of health care services, N. Y. Soc. Serv. Law § 367-a.1 (McKinney Supp. 1981).3
At the time their complaint was filed, respondents Yaretsky and Cuevas were patients in the American Nursing Home, an SNF located in New York City.4 Both were recipients of assistance under the Medicaid program.5 In December 1975 the nursing home's URC decided that respondents did not need the care they were receiving and should be transferred to a lower level of care in an HRF.6 New York City officials, who were then responsible for administering the Medicaid program in the city, were notified of this decision and prepared to reduce or terminate payments to the nursing home for respondents' care.7 Following administrative hearings, state social service officials affirmed the decision to discontinue benefits unless respondents accepted a transfer to an HRF providing a reduced level of care.8
Respondents then commenced this suit, acting individually and on behalf of a class of Medicaid-eligible residents of New York nursing homes.9 Named as defendants were the Commissioners of the New York Department of Social Services and the Department of Health.10 Respondents alleged in part that the defendants had not afforded them adequate notice either of URC decisions and the reasons supporting them or of their right to an administrative hearing to challenge those decisions.11 Respondents maintained that these actions violated their rights under state and federal law and under the Due Process Clause of the Fourteenth Amendment.12 They sought injunctive relief and damages.13
In January 1978 the District Court certified a class and issued a preliminary injunction, restraining the defendants from reducing or terminating Medicaid benefits without timely written notice to the patients, provided by state or local officials, of the reasons for the URC decision, the defendants' proposed action, and the patients' right to an evidentiary hearing and continued benefits pending administrative resolution of the claim.14 In October 1979 the District Court approved a consent judgment incorporating the relief previously awarded by the preliminary injunction and establishing additional substantive and procedural rights applicable to URC-initiated transfers to lower levels of care.15 The consent judgment left several issues of law to be decided by the District Court.16 The most important, for our purposes, was "whether there is state action and a constitutional right to a pre-transfer evidentiary hearing in a patient transfer to a higher level of care and/or a patient transfer initiated by the facility or its agents."17 Ultimately, the District Court answered that question in respondents' favor, although without elaborating its reasons.18 The court permanently enjoined petitioners, as well as all SNF's and HRF's in the State, from permitting or ordering the discharge of class members, or their transfer to a different level of care, without providing advance written notice and an evidentiary hearing on "the validity and appropriateness of the proposed action."19
The Court of Appeals for the Second Circuit affirmed that portion of the District Court's judgment described above.20 629 F. 2d 817 (1980). The court held that URC-initiated transfers from a lower level of care to a higher one, and all discharges and transfers initiated by the nursing homes or attending physicians, "involve state action affecting constitutionally protected property and liberty interests."21 The Supreme Court granted certiorari to consider the Court of Appeals' conclusions about the nature of state action.22 454 U. S. 815 (1981). The Court reversed the judgment.
Whether respondents have standing to challenge the procedural adequacy of facility-initiated discharges and transfers to lower levels of care?23
A plaintiff must show that he personally has suffered some actual or threatened injury as a result of the putatively illegal conduct of the defendant.24 It is not enough that the conduct of which the plaintiff complains will injure someone.25 The complaining party must also show that he is within the class of persons who will be concretely affected.26
Yes. Respondents Yaretsky and Cuevas were Medicaid patients in a skilled nursing facility whose utilization review committee determined in December 1975 that they should be transferred to a lower level of care in a health related facility.27 State officials were notified and prepared to reduce benefits.28 After hearings, state officials affirmed the decision.29
Although the October 1979 consent judgment addressed URC-initiated transfers to lower levels of care, the nursing homes remain free to determine independently that continued stay at the current level is not medically necessary.30 The possibility that the homes will exercise this authority is realistic.31 Similar determinations had already been made by the committees of physicians chosen by the facilities.32 Past wrongs supply evidence bearing on the likelihood of repeated injury.33
Respondents possess Article III standing to challenge the procedural adequacy of facility-initiated discharges and transfers to lower levels of care.34
Whether respondents have standing to challenge the procedural adequacy of transfers to higher levels of care?35
Article III requires a plaintiff to demonstrate a sufficiently real and immediate threat of injury that is not imaginary or speculative.36 Nor does a plaintiff who has been subject to injurious conduct of one kind possess by virtue of that injury the necessary stake in litigating conduct of another kind, although similar, to which he has not been subject.37 The conditions under which such transfers occur are sufficiently different from those which respondents do have standing to challenge that any judicial assessment of their procedural adequacy would be wholly gratuitous and advisory.38
No. Nothing in the record available to this Court suggests that any of the individual respondents have been either transferred to more intensive care or threatened with such transfers.39 It is not inconceivable that respondents will one day confront this eventuality, but assessing the possibility now would take us into the area of speculation and conjecture.40 Transfers to higher levels of care are recommended when the patient's medical needs cannot be satisfied by the facility in which he or she currently resides.41 Transfers to more intensive care typically result in an increase in Medicaid benefits.42
Respondents' constitutional attack on discharges or transfers to a lower level of care presupposes a deprivation of protected property interests.43 Since July 1978, petitioners have adhered to a policy permitting Medicaid patients to refuse URC-recommended transfers to higher levels of care without jeopardizing their Medicaid benefits.44
Respondents lack Article III standing to challenge the procedural adequacy of transfers to higher levels of care.45
Whether decisions by privately owned nursing homes to discharge or transfer Medicaid patients constitute state action for purposes of the Fourteenth Amendment?46
The Fourteenth Amendment provides that no State shall deprive any person of life, liberty, or property, without due process of law.47 The Amendment applies only to state action.48 The challenged conduct must be fairly attributable to the State.49 A State normally can be held responsible for a private decision only when it has exercised coercive power or has provided such significant encouragement, either overt or covert, that the choice must in law be deemed to be that of the State.50 Mere approval of or acquiescence in the initiatives of a private party is not sufficient to justify holding the State responsible for those initiatives under the Fourteenth Amendment.51 The required nexus may be present if the private entity has exercised powers that are traditionally the exclusive prerogative of the State.52
No. The decisions about which respondents complain are made by physicians and nursing home administrators, all of whom are concededly private parties.53 There is no suggestion that those decisions were influenced in any degree by the State's obligation to adjust benefits in conformity with changes in the cost of medically necessary care.54 Those decisions ultimately turn on medical judgments made by private parties according to professional standards that are not established by the State.55 The nursing homes do not perform a function that has been traditionally the exclusive prerogative of the State.56
The Medicaid statute requires that the States provide funding for skilled nursing services as a condition to the receipt of federal moneys.57 It does not require that the States provide the services themselves.58 The state constitutional provisions cited by respondents do no more than authorize the legislature to provide funds for the care of the needy.59 They do not mandate the provision of any particular care, much less long-term nursing care.60
Decisions by privately owned nursing homes to discharge or transfer Medicaid patients do not constitute state action for purposes of the Fourteenth Amendment.61
Related opinions on this issue
Joined by Justice Marshall
Justice Brennan dissented on the ground that the nursing homes in this case are heavily regulated by the State.62 They are licensed by the State and receive virtually all of their funding from the State through the Medicaid program.63 The State has delegated to the nursing homes the responsibility for making decisions that directly affect the patients' eligibility for Medicaid benefits.64
Under these circumstances, the nursing homes' decisions must be considered state action.65 The level-of-care decisions at issue in this case have far less to do with the exercise of independent professional judgment than they do with the State's desire to save money.66 The two levels of long-term institutionalized care enshrined in the Medicaid scheme are legislative constructs, designed to serve governmental cost-containment policies.67
The Court today departs from the Burton precept, ignoring the nature of the regulatory framework presented by this case in favor of the recitation of abstract tests.68 Justice Brennan would affirm the judgment of the Court of Appeals.69