Advocate Christ Medical Center v. Kennedy, Docket No. 23-715

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When it comes to the rules around Medicare and hospital funding, the details can get pretty tricky. In the case of Advocate Christ Medical Center v. Kennedy, the Supreme Court looked at how hospitals get extra money for treating low-income patients. The question was about who counts as "entitled" to certain government benefits—specifically, supplementary security income, or SSI—when hospitals figure out how much extra funding they should get.

The Court decided that a patient is only considered "entitled" to SSI benefits if they’re actually eligible to receive a cash payment during the month they’re in the hospital. This might sound like a small detail, but it changes which patients hospitals can count when they ask for more money to help cover the costs of caring for people with lower incomes. The decision means that only those patients who could get an SSI payment that month will be included in the hospital’s calculations for extra Medicare funding.

Summary of the Case

Advocate Christ Medical Center v. Kennedy concerns the calculation of the "disproportionate share hospital" (DSH) adjustment under Medicare, which provides additional funding to hospitals serving a high percentage of low-income patients. The DSH adjustment is determined by a formula that includes the "Medicare fraction," which counts the number of hospital patient days attributable to Medicare patients who are also "entitled to [Supplemental Security Income (SSI)] benefits." The Department of Health and Human Services (HHS) interpreted this to mean only those patients eligible to receive an SSI cash payment during the month of hospitalization. Over 200 hospitals challenged this interpretation, arguing that all patients enrolled in the SSI system at the time of hospitalization should be counted, even if they did not receive a payment that month. The hospitals claimed HHS’s approach undercounted low-income patients and led to underfunding from 2006 to 2009. The lower courts sided with HHS, and the Supreme Court granted certiorari to resolve the statutory interpretation of "entitled to [SSI] benefits" (see Syllabus, pp. 1–3).

Opinion of the Court

Justice Barrett, writing for the majority, held that for purposes of the Medicare fraction, an individual is "entitled to [SSI] benefits" only when eligible to receive an SSI cash payment during the month of hospitalization. The Court reasoned that SSI benefits, as defined by statute, are cash benefits determined on a monthly basis (42 U.S.C. §§1381a, 1382(b), 1382(c)). The Court rejected the hospitals’ broader reading, which would have included non-cash benefits or all SSI enrollees regardless of monthly eligibility. The majority emphasized that the statutory language and structure focus on monthly eligibility for cash payments, not broader program enrollment or ancillary benefits. The Court also distinguished this case from its prior decision in Becerra v. Empire Health Foundation, noting that the entitlement structure of SSI (monthly, means-tested, and not automatic) differs from Medicare Part A (automatic and ongoing). The Court concluded that Congress chose a specific, administrable formula, and the judiciary must respect that choice, even if it is imperfect (Opinion, pp. 6–16).

Dissenting Opinions

Justice Jackson, joined by Justice Sotomayor, dissented. The dissent argued that the majority misunderstood the nature of SSI, which is designed as a safety net guaranteeing a minimum income for low-income individuals. Justice Jackson contended that "entitlement" to SSI should be understood as program enrollment, not just monthly payment eligibility, because the benefit is the security of coverage, not merely the receipt of a check. The dissent criticized the majority’s approach as arbitrary, noting that it could exclude low-income patients from the DSH calculation based on the timing of their income fluctuations, rather than their overall economic status. Justice Jackson also argued that the majority’s interpretation undermines Congress’s intent to support hospitals serving the neediest populations and is inconsistent with the Court’s prior reasoning in Empire Health, which focused on program eligibility rather than payment receipt (Dissent, pp. 2–18).

Determining Poverty Status

The legal nuance centers on the interpretation of "entitled to [SSI] benefits" in 42 U.S.C. §1395ww(d)(5)(F)(vi)(I). The statute’s language is technical and embedded in a complex reimbursement scheme. SSI is a means-tested program providing monthly cash payments to eligible individuals, with eligibility determined each month based on income and resources (42 U.S.C. §§1381a, 1382(a)-(c)). The DSH adjustment formula uses the Medicare fraction to approximate the share of low-income Medicare patients, but Congress chose to use monthly SSI payment eligibility as a proxy for poverty status. This choice reflects a legislative compromise balancing accuracy, administrability, and resource allocation. The majority’s interpretation adheres closely to the statutory text and structure, emphasizing the importance of monthly eligibility and the cash nature of SSI benefits. The dissent, by contrast, reads the statute in light of its broader remedial purpose and the practical realities of poverty, advocating for a more inclusive approach that would better capture the population Congress intended to benefit. This case illustrates the tension between textualist and purposivist statutory interpretation, especially in the context of complex social welfare legislation (see Opinion, pp. 6–16; Dissent, pp. 2–18).