## Facts

- A certified class of Colorado Medicaid recipients residing in nursing homes sued federal officials responsible for administering and enforcing Medicaid nursing-home standards.
- Michael Patrick Smith, a Medicaid recipient with muscular dystrophy, was the original named plaintiff; after his death, his estate continued the litigation.
- Plaintiffs alleged that residents were denied the quality of medical and psychosocial care required by the Medicaid Act.
- Plaintiffs challenged the federal oversight and enforcement approach, asserting it was “facility oriented,” emphasizing structural and documentation compliance rather than the care actually delivered to residents.
- Plaintiffs sought to require the Secretary of Health and Human Services to implement a “patient oriented” review and enforcement system that would better ensure high-quality care.
- The district court found a patient-care-oriented system feasible but ruled the Secretary had no statutory duty to develop or require it, placing primary responsibility on the state.

## Issues

1. Whether the Secretary of Health and Human Services has a statutory duty under the Medicaid Act to develop and implement a nursing-home review and enforcement system designed to ensure Medicaid recipients actually receive high-quality medical and psychosocial care.
2. If such a duty exists, whether the Secretary’s facility-oriented enforcement approach satisfies the Medicaid Act’s requirements.

## Decision

- The Tenth Circuit reversed the district court.
- The court held that the Medicaid Act imposes a statutory duty on the Secretary to establish an enforcement system that adequately ensures facilities receiving federal Medicaid funds provide high-quality patient care.
- The court held that a facility-oriented, paper-focused approach that does not adequately assess actual care delivered does not satisfy the Secretary’s statutory obligations.
- The court concluded the Secretary’s failure to implement an adequate, patient-focused enforcement regime was arbitrary and capricious.
- The court held mandamus was an appropriate remedy to compel the Secretary to perform the statutory duty.

## Legal Principles

- The Medicaid Act’s focus is the provision of care to beneficiaries; federal oversight cannot be limited to evaluating a facility’s theoretical capacity or documentation compliance.
- The Secretary’s federal role includes ensuring substantive compliance with Medicaid care standards, not merely distributing funds or relying on state assurances.
- Statutory “look-behind” authority supports an obligation for independent federal verification of compliance with care requirements rather than acceptance of state certifications at face value.
- When a clear statutory duty exists and the responsible federal official fails to act in a legally adequate manner, mandamus may issue to compel performance.

## Conclusion

The Tenth Circuit required federal Medicaid enforcement to be oriented toward whether residents actually receive the quality of care mandated by statute, rejected a paper-compliance model as insufficient, and authorized mandamus to compel the Secretary to implement an effective patient-care-focused oversight system.


In re Estate of Smith v. Heckler, 747 F.2d 583 (10th Cir. 1984)