Vol. 24 Annals of Health Law 389
will similarly be available to enforce applicants’ federal rights. 381
However, plaintiffs seeking to litigate against the private non-profit and
quasi-public Marketplaces may face new hurdles. Even where private contractors took on responsibilities administering Medicaid, the single state
agency remains ultimately responsible for the private contractors’ actions. 382 The Fourth Circuit recently explained that the single state agency
requirement is justified by efficiency and accountability rationales:
From an efficiency perspective, the requirement ensures that final authority to make the many complex decisions governing a state’s Medicaid
program is vested in one (and only one) agency. The requirement thereby
avoids the disarray that would result if multiple state or even local entities were free to render conflicting determinations about the rights and
obligations of beneficiaries and providers . . . . With respect to the accountability rationale, the vesting of responsibility over a state’s Medicaid program in a single agency safeguards against the possibility that a
state might seek to evade federal Medicaid requirements by passing the
buck to other agencies that take a less generous view of a particular obligation. 383
The Fourth Circuit held that the single state agency’s ultimate authority
extended even to litigation decisions. 384 A private insurance company that
contracted with the state Medicaid agency to provide managed care services
to North Carolina’s beneficiaries could not independently appeal a decision
by the district court that the state agency chose not to appeal. 385
Gillian Metzger, a constitutional law scholar, made related arguments
about the importance of clear accountability mechanisms for private entities
that contract to provide government services. She has described the particular importance (and difficulty) of ensuring procedural due process protections when private entities determine third-parties access to government
benefits. 386 Accountability and government oversight of private delegations
are important for two reasons, she argues. First, it is important because the
government can benefit and learn from the private expertise and innovation. 387 Second, accountability is necessary to ensure continued public control of government programs and to guard against self-interested private de-
381. See DASH ET AL., supra note 189, at 10 (Kentucky, Nevada, New York, Rhode Island, Utah, and Vermont used a state agency structure).
382. K. C. ex rel v. Shipman, 716 F.3d 107, 112 (4th Cir. 2013).
386. Gillian Metzger, Private Delegations, Due Process and the Duty to Supervise in
GOVERNMENT BY CONTRACT, 291, 295 (Jody Freeman & Martha Minor, eds.) (2009).
387. Id. at 296.