Full opinion text
AMENDED RULING ON DEFENDANT’S MOTION TO DISMISS AND RULING ON PLAINTIFFS’ REQUEST FOR A PRELIMINARY INJUNCTION. JUDGE JOHN W. deGRAVELLES, UNITED STATES DISTRICT COURT, MIDDLE DISTRICT OF LOUISIANA 1. INTRODUCTION Before the Court is the Renewed Motion for Temporary Restraining Order and Preliminary Injunction filed by Planned Parenthood Gulf Coast, Iric; (“PPGC” or “Planned Parenthood”), appearing on behalf of both itself and three patients— Jane Does #1, 2;- and’ 3 (“Individual Plaintiffs”) (collectively, “Plaintiffs”) — and based on Section 1396a(a)(23)(A) of the United States Code’s Forty-Second Title (“Medicaid Act”) and the First and Fourteenth Amendments of the United States Constitution. (Doc. 46 at 17-26; Doc. 53 ¶¶ 62-67 at 19-20; Doc. '45 at 1-2.) The arguments made in support of this motion appear in the Memorandum of Law in Support of Plaintiffs’ Renewed Motion for Temporary Restraining Order and Preliminary Injunction (“Plaintiffs’ Renewed Memorandum”), (Doc. 46), and Memorandum Regarding Availability of State Remedy (“Plaintiffs’ Remedy Memorandum”), (Doc. 52). Plaintiffs’ request is opposed by Louisiana’s Department of Health and Hospitals (“DHH”), whose head, Secretary Kathy H. Kliebert, is being sued in her official capacity and is therefore this matter’s named defendant (“Kliebert” or “Defendant”). Defendant’s arguments are put forth in the Motion to Dismiss Complaint for Lack of Subject Matter Jurisdiction and Failure to State a Claim (“Motion to Dismiss”), (Doc. 53), supported by the attached Memorandum in Support of Motion to Dismiss Complaint for Lack of Subject Matter Jurisdiction and Failure to State a Claim (“Defendant’s Memorandum”), (Doc. 53-1). Although no evidentiary hearing was held, the matter was thoroughly briefed and argued. The Court has carefully considered the pleadings and briefings to date, which are discussed in more detail below. The Court also thoroughly considered the oral arguments and representations of counsel at hearings held on September 2, 2015 (“First Hearing”), and on October 16, 2015 (“Second Hearing”). On Sunday, October 18, this Court issued an order denying Defendant’s motion to dismiss and granting Plaintiffs’ request for a temporary restraining order, (Doc. 55). It set a status conference for the following day. At that status conference, all parties agreed that no further discovery and no further argument was necessary for this Court to make its determination on whether to issue a preliminary injunction, (Doc. 58). Both parties expressed “no objection to converting the temporary restraining order to a preliminary injunction.” (Id.) This agreement was reaffirmed in a telephone status conference on October 28, 2015. (Doc. 62.) By the Parties’ express consent, the evidentiary record has therefore been finalized, and any factual allegations left uncontroverted must be accepted as true. On October 28,2015, by way of Notice of Supplemental Authority, Plaintiffs brought to the Court’s attention a case decided the same day which addresses the identical issue confronting this Court, in which the court granted a preliminary injunction enjoining the Governor of Alabama and others from suspending Medicaid payments to Planned Parenthood Southeast, Inc. and from failing to reinstate the State’s provider agreement with that entity. (Doc. 61 (attaching Doc. 63, Planned Parenthood Se., Inc. v. Bentley, No. 2:15-cv-620-MHT-TFM (M.D. Ala. October 28, 2015) (Opinion) (“Bentley”)).) For the reasons first set out in the Order on Plaintiffs’ Motion for Temporary Restraining Order and Preliminary Injunction, (Doc. 55), and more fully set forth below, the Court determines that Plaintiffs have met their burden for a preliminary injunction to maintain the status quo. The Court therefore enjoins from suspending Medicaid payments to PPGC for services rendered to Medicaid beneficiaries, including but not limited to the Individual Plaintiffs pursuant to Federal Rule of Civil Procedure 65(b)(2). The preliminary injunction will remain in effect until it is revised, if at all, by this Court’s own further order or by a decision of the United States Court of Appeals for the Fifth Circuit (“Fifth Circuit”). For the reasons set forth hereinafter, the Court declines to require security under .Rule 65(c) from PPGC or the Individual Plaintiffs. IL FACTUAL AND STATUTORY BACKGROUND A. PARTIES Defendant is sued in her official capacity, as she is the head of DHH, (Doc. 1 ¶ 19 at 4; Doc 43 ¶.20 at 6; Doc. 53-1 at 1). DHH administers this state’s Medicaid Program, a dual state-federal assistance program for families and individuals with low income and limited resources encoded in 42 U.S.C. 1396 et seq. ‘(See also, e.g., Doc. 1 ¶ 20 at 5; Doc. 13-1 ¶¶ 1-4 at 1-2; Doc. 43 ¶ 20 at 6; Doc. 53-1 at 1-4.) DHH does so by monitoring the allocation of federal-state funds in Louisiana and submitting a state plan for medical assistance for review and approval to the Centers for Medicare and Medicaid Services (“CMS”), operating under a delegation of authority from the Secretary for the Department of Health and Human Services (“DHHS”). La. R.S. §§ 46:437:2(B), 46:437.13; 42 U.S.C. § 1396a(a); 42 C.F.R. 431.10. In accordance with the Louisiana Medical Assistance Programs Integrity Law (“MA-PIL”), Medicaid providers must sign a contract with DHH .and satisfy several requirements.- LA. R.S. §§ 46:437:11, 46:437.13. (See also Dóc. 13-1 ¶¶ 1-4 at 1-2.) DHH’s powers are circumscribed by statute while many of its relevant regulations appear in Title 50 of the Louisiana Administrative Code. (Doc. 53-1 at 2-4; see also Doc! 13-1 ¶ 3 at 1.) In this case, DHH initially invoked Section 46:437.11(D) (1), (Doc. 13 at 1-2,13,18; Doc. 53-1 at 1; Hr’g Tr. 11:25-12:8, Sept. 2,2015), and presently relies upon Sections 46.437(D)(2) and 46:437.14(A) and Title 50, (Doc. 39-1 at 1-2, ■ 5-6, 8-9,11-12; Doc. 53-1 at 3-4, 24). • ■ PPGC is a charitable organization, so classified under section 501(c)(3) of the Internal Revenue Code, 26 U.S.C. § 501(c)(1), U.S. Dep’t of the Treasury, Internal Revenue Serv., Form 990 at .1 (2012). (Doc. 43 ¶ 10 at 4; see also Doc. 4-2 ¶ 5 at 2.) Headquartered in Houston, Texas, it maintains its legal domicile in the Lone Star State, FORM 990 át 1, but is licensed to do business in Louisiana, (Doc. 43 ¶ 10 at 4; see also, e.g., Doc. 1 ¶ 9 at 3; Doc. 4-2 ¶ 5 at 2.) PPGC operates family planning centers and clinics in the Houston area of Texas and in Louisiana. (Doc. 43 ¶¶ 10-11 at 4; see also Doc. 1 ¶ 10 at 3-4.) Its first center founded in 1984, PPGC’s two Louisiana clinics — the Baton Rouge Health Center (“BRHC”). and the New Orleans Health Center (“NOHC”) — participate in Louisiana’s Medicaid Program, “providing medical services to low-income enrollees in both underserved communities.” (Doc. 1 ¶ 10 at 3-4; Doc. 43 ¶ 11 at 4; see also Hr’g Tr. 10:25-11:6, Sept. 2, 2015.) In fiscal year 2014, the two facilities in Louisiana served over 5,200 Medicaid patients and were visited by over 10,000 women...(Nee, e.g., Doc. 43 ¶ 13 at 4; Doc. 1 ¶ 40 at 11; Hr’g Tr. 8:23-24, Sept. 2, 2015.) “Nearly 75%”' of the visits to BRHC were by patients enrolled in Medicaid; “[n]early 40%” of appointments at NOHC were with similarly classified- individuals. (Doc. 3 ¶¶- 9-10 at 3-4; Doc. 43 ¶ 11 at 4.) “[Currently, over 60% of PPGC’s Louisiana visits are for patients enrolled in the Medicaid program.” (Doc. ¶ 13 at 4.) The services offered by these two centers include “physical exams, contraception and contraceptive counseling, screening for breast cancer, screening and treatment for cervical cancer, testing and treating for certain sexually transmitted diseases ..., pregnancy tésting and counseling, and certain procedures^] including colposcopy.” (Doc, 1. ¶ 10 at 3-4; Doc. 4-2 ¶ 8 at 3; Doc. 43 ¶ Í1 at 4; Hr’g Tr. 7:24-8:7, 8:16-9:9, Sept. 2, 2015.) Neither BRHC. nor NOHC performs abortions. (Doc. 1 ¶ 11 at 4; Doc. 43 ¶ 12 at 4; Doc. 46-1 ¶ 5 at 2; Hr’g Tr. 21:22-25:3, Oct. ’ 16, 2015.) Neither - currently has or has ever had a fetal tissue donation program. (Doc. 46 at 11; Do'c. 46-1 ¶ 21 at 6.) The Individual Plaintiffs rely upon Medicaid and receive their medical care from one of PPGC’s two facilities. (Doc. 4-3, 4-4, 4-5.) They wish to continue to obtain their reproductive care from PPGC and do not know where they could elsewhere get the same kind of care. (Doc-. 4-3 ¶¶ 6-7 at 2; Doe. 4-4 ¶ 8 at 2; Doc. 4-5 ¶ 6 at 2; Hr’g Tr. 8:23-9:9, Sept. 2, 2015.) Jane Doe #2 became a patient at NOHC after her former doctor refused to accept Medicaid, (Doc. 4-4 ¶ 3 at 1), and Jane Doe #2 has found it “very difficult to find doctors in Baton Rouge who will accept Medicaid,” (Doc. 4-5 ¶ 3 at 1). In this proceeding, they are intended to represent the interests of many of PPGC’s other Medicaid patients throughout the state of Louisiana. (See, e.g., Doc. 46 at 29-30; Doc. 49-1 at 10.) B. PRECIPITATING EVENTS ' On February 19, 2014, pursuant to the concurrent resolutions of Louisiana’s House of Representatives and Senate, the Louisiana Legislative Auditor (“Auditor”) reviewed “a sample of Medicaid payments DHH during calendar year 2012 to determine if they were appropriate and supported.” (Doc. ■ 46-1 at 14 (Louisiana Legislative Auditor, Response to. Senate Concurrent Resolution No. 57 and House Resolution No. 105, 2013 Regular session 1 (Feb.' 19, 2014)). “Overall,” the resulting report (“Legislative Audit”) “found that DHH [only] made payments to Planned Parenthood for allowable family planning procedure codes under Medicaid” and unearthed no “indication that Planned Parenthood recommended an abortion or performed an abortion for th[ose] patients. (Id.)- More specifically, having “extracted and analyzed claims data for all 25,936 claims DHH paid to Planned Parenthood for Medicaid reimbursements during calendar year 2012,” the Legislative Auditor “did not find any evidence that Medicaid payments to Planned Parenthood were not made ... for allowable Family Planning procedure codes,” (Id. at 15 (emphasis added).) From these 25,936 claims, the Auditor “identified 22 patients that subsequently suffered a miscarriage”' and failed to find “any indication that Planned, Parenthood recommended an abortion or performed an abortion for these patients.” (Id.) Under Louisiana law, the Legislative Audit is “a public document” and was “distributed to appropriate public officials'.” (Id.) In July 2015, the Center for Medical Progress (“CMP”) released a series of edited videos which purported to document discussions regarding the acquisition of tissue samples between various Planned Parenthood affiliates’ officials 'and disguised actors. See Kevin Litten, Bobby Jindal Announces Investigation into Planned Parenthood, The Timés-Picayune, July 14, 2015; Planned Parenthood Exposed: Examining the Horrific Abortion Practices at the Nation’s Largest Abortion Provider: Hearing Before the H. Comm on Judiciary, 114th Cong. 192-201 (2015) (Analysis of CMP Video by Fusion GPS). Thereafter, DHH exercised its “oversight over all health' facilities in the state” and requested that PPGC “answer some simple questions about ... [its] current operations and planned operations in Louisiana,” (Doc. 46-1 at 51-52 (Letter from Kathy Kliebert, Sec’y, Dep’t of Health & Hosps., State of Louisiana, to Melaney Linton, Pres., Planned Parenthood Gulf Coast, Inc. (July 15, 2015)) (“Defendant’s July Letter”). DHH gave PPGC until July 24, 2015, to respond. (Id. at 51.) On July 24, 2015, PPGC did so. (Doc. 46-1 at 54-58 (Letter from Melaney A. Linton, Pres. & CEO, Planned Parenthood Gulf Coast, Inc., to Kathy Kliebert, Sec’y, Dep’t of- Health. & Hosps., State of Louisiana (July 24, 2015)) (“PPGC’s July Letter”). This letter recaps PPGC’s history in Louisiana and denies the accusations made by CMP. (Id. at 54-t55.) In it, Ms. Melaney A. Linton, PPGC’s President and Chief Executive Officer and this letter’s author (“Ms. Linton”), clarifies that, PPGC “does not offer abortion services” in Louisiana. (Id. at 55.) PPGC acknowledged its link to Planned Parenthood Center for Choice, Inc. (“PPCFC”), ,a “standalone corporation” and a department of PPGC until 2005, and described itself as an “affiliate” of Planned Parenthood Federation of America (“PPFA”). (Id.) PPGC then responded to each of Defendant’s questions, emphasizing that neither PPGC nor PPCFC provide abortion services in Louisiana. (Id. at 55, 57.) To the question of whéther any PPGC “facilities, or any affiliates, subsidiaries, or associates .thereof, sell or donate -any unborn baby organs or body parts,” PPGC answered, “No.” (Id. at 56.) To another — “How many clinics operated by Planned Parenthood Gulf Coast, or any affiliates, subsidiaries, or associates thereof, do business with ... any ... organizations in the business of selling or donating the remains of unborn babies?” — PPGC answered, “None”. (Id.) On August 4, 2015, Defendant sent a second letter to PPGC. (Id. at 60-61 (Letter from Kathy Kliebert, Sec’y, Dep’t of Health & Hosps., State of Louisiana, to Melaney Linton, Pres., Planned Parenthood Gulf Coast, Inc. (Aug. 4, 2015)) (“Defendant’s August Letter”). It zeroes in on three statements in PPGC’s July Letter: “PPCFC does not have a fetal tissue donation program in Texas currently”; “PPCFC disposes of Pathological Waste through an entity that is licensed for disposal of Special Waste from Health Care-Related Facilities”; and its “No” response to the question of whether “any Planned Parenthood Gulf Coast facilities, or any affiliates, subsidiaries, or associates thereof, sell or donate any unborn baby organs or body parts.” (Id. at 60.) Defendant characterized these answers as being “directly contradict[ed]” by another “recently released video made on April 9, 2015 at the Planned Parenthood facility in Houston, Texas, in which Melissa Farrell, Director of Research at Planned Parenthood Gulf Coast (PPGC), discusses existing contracts for fetal tissue donation for the purpose of research.” (Id.) On August 14, 2015, PPGC responded. (Doc. 46-1 at 63 (Letter from Melaney A. Linton, Pres. & CEO, Planned Parenthood Gulf Coast, Inc., to Kathy Kliebert, Sec’y, Dep’t of Health & Hosps., State of Louisiana (Aug. 14, 2015) (“PPGC’s August Letter”)) (“PPGC’s August Letter”) On behalf of both PPGC and PPCFC, Ms. Linton denied the existence of any contradiction, as “neither PPCFC nor PPGC currently has a fetal tissue donation program in Texas, and neither sells nor donates fetal tissue.” (Id. at 63.) The letter proceeds to address each new question posed in Defendant’s August Letter, (Id. at 64-65.) C. OVERVIEW OF THE FIRST AND SECOND TERMINATION ACTIONS 1. First Termination Letters, Kennedy Declarations, and CMS’ Statement of Interest On August 3, 2015, Defendant notified PPGC of its intent to terminate the Agreements pursuant to § 46:137.11(D)(1) via four letters (“First Termination Letters”). (Doc. 1 ¶ 30 at 8; Doc. 13 at 1.) As this statute required, DHH gave PPGC 30-days’ notice from the relevant letters’ receipt. (Doc. 13 at 1-2.) The letters gave no reason for DHH’s decision. (Doc. 1 ¶ 32 at 8; see also Doc. 13 at 18, 20; Hr’g Tr.-14:6-8, Sept. 2, 2015.) In response, Plaintiffs filed their first complaint. (Doc. 1.) On that day, the Honorable Piyush “Bobby” Jindal, governor of Louisiana (“Jindal” or “Governor”), published a press release announcing the Agreements’ looming terminations. Press Release, Hon. Bobby Jindal, Governor of Louisiana, Governor Jindal Announces the Termination of Medicaid Contract with Planned Parenthood (Aug. 3, 2015). This document states: “Governor Jindal and DHH decided to give the required 30-day notice to terminate the Planned Parenthood Medicaid provider contract because Planned Parenthood does not represent the values of the State of Louisiana in regards to respecting human life.” Id. It continues: “Planned Parenthood does not represent the values of the people of Louisiana and shows a fundamental disrespect for human life,” and, “It has become clear that this is not an organization that is worthy of receiving public assistance from the state.” Id. It refers to the possibility that PPGC “could be acting in violation of Louisiana law that states no person or group contracting with the state or receiving governmental assistance shall require or recommend that any women have an abortion.” Id. It concludes: “Pending the ongoing investigation, DHH reserves the right to amend the cancellation notice and terminate the provider, agreement immediately should cause be determined.” Id. During the First Termination Action, among the many documents docketed by the Parties, Defendant submitted a declaration by Ms. J. Ruth Kennedy (“Ms. Kennedy”), the Medicaid Director of DHH (“First Kennedy Declaration”), (Doc. 13-2 ¶¶ 1-5 at 1). (Doc. 13 at 21-22.) The First Kennedy Declaration’s sixth paragraph states: “There are no Medicaid services that only family planning clinics provide that could not be[]provided by other enrolled Medicaid providers-in the State of Louisiana, including in New Orleans and Baton Rouge.” (Doc. 13-2 ¶ 6 at 2.) Its seventh further explains: “Any physi-eian/physieian extender and appropriately certified lab can provide family planning and related services as long as it is within their license and scope.” (Id. ¶ 7, at 2.) Per the next paragraph, “[t]here are 1,146 actively enrolled Medicaid providers in Region 1, covering the Greater New Orleans area, and 864 actively enrolled Medicaid providers in Region 2, covering the Greater Baton Rouge area, that can provide family planning and related services.” (Id, ¶ 8 at 2; see also Doc. 13 at 21.) A sorted provider list is attached; it includes dermatologists, dentists, audiologists, cosmetic surgeons, and orthopedic surgeons. (Doc. 13-2 at 5-41; see also Hr’g Tr. 23:18-25:2, Sept. 2,2015.) . This First Kennedy Declaration also' describes two telephonic conferences between CMS and DHH officials. According to Ms. Kennedy, on August 6, 2015, CMS advised DHH that the latter “has the authority to withhold federal Medicaid dollars from Louisiana or seek injunctive relief for the failure to comply with the Medicaid Act.” (Doc. 13-2 ¶ 10 at 2.) CMS and DHH held a second conference call on August 21, 2015, in which CMS “advised” DHH “it would be sending a letter ... confirming what CMS and HHS counsel had verbally conveyed to the Department during the August 6, 2015 conference call.” (Id. ¶ 11 at 2.) ‘ On August 31, 2015, the United States Department of Justice, on behalf of CMS and DHHS, filed a Statement of Interest. (Doc. 24.) The United States did so due to “its- strong interests in the proper operation of the Medicaid program ... and in ensuring that the [s]tates administer their federally-subsidized Medicaid programs in a manner that is consistent with the Medicaid • statute.” (Id. at 2.) Basically, the Statement of Interest makes three broad points. First, because DHH has sought to terminate the Agreements “without providing any justification related to PPGC’s qualifications to provide medical services,” DHH’s proposed termination will run afoul of § 1396a(a)(23). (Id.; see also Doc. 22 at 2, 5, 6.) To read Section 1396a(a)(23) differently would both “strip the Medicaid Act’s free choice of provider provision of all meaning.” (Doc. 24 at 3.) It would simultaneously “contravene clear congressional intent to give Medicaid beneficiaries the right to receive covered services from, any qualified and willing provider.” (Id.) Second, the Statement of Interest declares that DHH’s interpretation is “inconsistent” with “the overwhelming weight of authority” and with DHHS’ own . “considered and longstanding views.” (Id. at 3, 4, 19-22.) It describes DHH’s interpretation of Section 1396a(a)(23) as “not even a plausible reading of the statute,” “certainly not compelled by the text of the provision,” and likely to “undermine[ ] the provision’s intent.” (Id. at 20.) Meanwhile, DHHS “has repeatedly and consistently interpreted the ‘qualified’ language in § 1396a(a)(23) to prohibit a State from denying access to a provider for reasons unrelated to the ability of. that provider to perform Medicaid-covered services or to properly bill for those services.” (Id. at 3-4.) Its view “is eminently reasonable,” verified by a dictionary, and recognizes “[a] role for States to set reasonable restrictions related to a provider’s ability to provide competent and skilled services” without “reading]” Section 1396a(a)(23) “out of the statute altogether, as Louisiana desires.” (Id. at 21.) It contends that this interpretation, made by CMS “under authority delegated to it by Congress,” merits deference. (Id.) Finally, the Statement of Interest affirms CMS’ view that “Medicaid beneficiaries” like the Individual Plaintiffs “may enforce their statutory rights under §. 1396a(a)(23) to their choice of a qualified provider through a private action under 42 U.S.C. § 1983” even after Armstrong v. Exceptional Child Ctr., Inc., — U.S. -, 135 S.Ct. 1378, 1382, 191 L.Ed.2d 471 (2015) (“Armstrong”). (Doc. 24 at 2, 21; see also Doc. 22 at 2-5.) 2. First Hearing On September 2, 2015, the First Hearing was held. (Doc. 30.) During its course, the Parties’ positions on Section 1396a(a)(23) were clarified. Plaintiffs’ counsel explained: “We’re here because the termination violates the Jane Doe Plaintiffs’ .., right to free choice of provider under Section [1396]a(a)(23) of the Medicaid Act.” (Hr’g Tr. 4:10-12, Sept. 2, 2015.) Because PPGC is “competent to provide services,” it argued that it was “qualified” within this subsection’s meaning. (Hr’g Tr. 4:16-5:12, Sept. 2, 2015.) The claim before the Court in the Motion for TRO wait the Individual Plaintiffs’ claims under this provision of the “federal Medicaid act,” Plaintiffs’ counsel emphasized. (Hr’g Tr. 10:17-19, Sept. 2, 2015.) In Plaintiffs” view, whether or not PPGC held some administrative right was irrelevant, as the Individual Plaintiffs always lacked such prerogatives. (Hr’g Tr. 10:15-19, Sept. 2, 2015.) On the Individual Plaintiffs’ behalves, PPGC contested Defendant’s claim that Section 1396a(a)(23) creates no private cause of action. (Hr’g Tr. 4:10-15, 6:23-7:15, Sept. 2, 2015.) Specifically, it argued that it “clearly fulfills the standard set forth by the Supreme Court in Bless ing [v. Freestone, 520 U.S. 329, 117 S.Ct. 1353, 137 L.Ed.2d 569 (1997) (“Blessing ”),] and then in the Gonzaga [University v. Doe, 536 U.S. 273, 122 S.Ct. 2268, 153 L.Ed.2d 309 (2002) (“Gonzaga”),] ... cases.” (Hr’g Tr. 6:13-19, Sept. 2, 2015.) In other words, this subsection uses “rights creating language that unambiguously confers a right on Medicaid patients” and is not “so vague and amorphous that ... [it would] strainf ] judicial competence to enforce.” (Hr’g Tr. 6:15-19, Sept. 2, 2015.) Plaintiffs sought to distinguish the more recent Armstrong from the body of law spawned by these cases by maintaining that it not only dealt with “a completely different section of the Medicaid Act,” one “without the same kind of rights creating language,” but also lacked any Section 1983 claim. (Hr’g Tr. 6:24-7:4, 7:7-15, Sept. 2, 2015.) Defendant’s counsel countered that Section 1396a(a)(30) was substantially identical to Section 1396a(a)(23). These two subsections have “the exact same rights creating type of language”; both “say what the state plan should provide.” (Hr’g Tr. 16:17-22, Sept. 2, 2015.) He thus urged the Court to adopt the reasoning of the plurality in Armstrong. (Hr’g Tr. 14:10-15:8, 16:4-10, 16:13-14, 19:21-24, 22:24, 23:13 14, Sept. 2, 2015.) Defendant’s counsel also insisted that Section 1396a(a)(23)’s “qualified” requirement was “a very vague standard.” (Hr’g Tr. 18:1-2, Sept. 2, 2015.) Having proposed a number of denotations, (Doc. 13 at 8), Defendant’s counsel based this conclusion on his “conversations” with CMS and the supposed “[un]reasonabl[eness]” of CMS’ contrary interpretation, (Hr’g Tr. 16:24-17:10, 17:24-18:9, Sept. 2, 2015). Because “qualified” is inherently vague and ambiguous, Section 1396a(a)(23) cannot meet the Blessing test’s requirement that a right not be “so vague and amorphous as to be beyond the competence of the judiciary to enforce.” (Doc. 13 at 4, 8.)- Defendant promised to “flesh out” her position in a response to the Statement of Interest, (Hr’g Tr. 17:1-2, Sept. 2, 2015.) PPGC’s competence to- provide the Medicaid services was also .discussed. In response to this Court’s question regarding whether DHH had yet “raised any suggestion or made any suggestion that the reason for terminating the contract has anything to do with competency or the adequacy of the care that is given” by PPGC “to the patients who get their care at those facilities,” Plaintiffs'- counsel answered, “No.” (Hr’g Tr. 3:19-24, Sept. 2, 2015.) When this Court posed the same question to Defendant’s counsel — “There is no question ... about the competency of these two facilities to provide Medicaid services and adequate care for the patients that they serve, would you agree with that?” — Defendant’s counsel answered,-“At this time, I would agree with that.” (Hr’g Tr. 11:11-16, Sept. 2, 2015.) Additionally, when asked, “They’re not qualified because you’re terminating their contract?’.’ Defendant’s counsel answered, “Exactly,” and admitted that DHH’s definition of “qualified” was “circular”: PPGC was no longer a “qualified” provider because DHH had made it so by terminating their contract, a mechanism he then stated had never béforé been utilized in quite this manner. (Hr’g Tr. 21:10-13, 22-25, 22:10-13, Sept. 2, 2015.) He also acknowledged that the “current motive” or “the motive leading up to” the Agreements’ termination was CMP’s video tapes. (Hr’g Tr. 12:8-16, Sept. 2, 2015; see also Hr’g Tr. 35:12-19, Oct. 16, 2015.) The Parties finally contested the capacity of this state’s other Medicaid providers to absorb PPGC’s patients. PPGC characterized the list included with the First Kennedy Declaration as containing “numerous examples of[,] on their face[,] providers that would not provide the care that Planned Parenthood provides, including dentists, radiologists, nursing homes, [and other] places that are not going to do breast cancer screening or give out birth control.” (Hr’g Tr. 8:18-22, Sept. 2, 2015.) PPGC maintained that “there’s no way that ... other alternative providers have the capacity to absorb our patients.” (Hr’g Tr. 9:2-4, Sept. 2, 2015.) Defendant’s counsel admitted that the Individual Plaintiffs would suffer “disruption of some kind,” being forced, “to get other doctors” and “seek out other places to get their health care.” (Hr’g Tr. 13:6-12, Sept. 2, 2105.) Defendant’s counsel also clarified the origins of the list of providers referenced in the Defendant’s Opposition and the First Kennedy Declaration. (Hr’g Tr. 23:18-25:9, Sept. 2, 2015.) It reflected “typically billed” codes, and was the result of “a code run” of providers that “can provide family planning services because they have billed for them” by Defendant. (Hr’g Tr. 24:4-6, 25:1-6, Sept. 2, 2015.) 3. Third Kennedy Declaration After the First Hearing, Defendant sought permission to amend its opposition and substitute new papers “pursuant to ... [its] duty to provide accurate information to the Court.” (Doc. 32 at 1.) Included in Defendant’s proposed amendments was a third declaration by Ms. Kennedy (“Third Kennedy Declaration”). This Third Kennedy Declaration corrects Defendant’s first list of providers, explaining: “I[, Ms. Kennedy,] ordered a comprehensive review of this exhibit and have since discovered that nursing facilities and dentists should not have been included.” (Doc. 34-2 ¶ 8a at 2; see also Doc. 34 at 2.) It adds: “The other provider types included in Exhibit 1 are appropriate due to what they are allowed to do under the scope of their license.” (Doc. 34-2 ¶ 8a at 2; see also Doc. 34 at 2.) It gives two other examples: “[Anesthesiologists, who can be reimbursed for their role in sterilization procedures[,] and radiologists, who can be reimbursed for reading ultrasounds, etc. related to reproductive/women’s health issues.” (Id.) This “review of the information in [the First Kennedy Declaration] also revealed a more precise description of Medicaid providers in the New Orleans and Baton Rouge areas other than PPGC who are available to patients seeking family planning and related services.” (Doc. 34 at 2.) Defendant’s staff had “gather[ed] information from available Medicaid providers in proximity to the two Planned Parenthood locations in New Orleans and Baton Rouge, Louisiana.” (Doc. 34-2 ¶ 8b at 2.) As a result of this additional inquiry, Ms. Kennedy had decided to cull the list of relevant providers from over one-thousand (2,000) to twenty-nine (29), (Compare Doc. 13-2 ¶ 8 at 2, with Doc. 34-2 at 5-6). This amended document includes two entries for the City of New Orleans Health Department, whose titles suggest one primarily serves and another mostly the homeless. (Id. at 5.) The Court also notes that the name of some of the other entities listed suggest that their patent base is similarly limited, e.g. “NO/Aids Task Force,” “New Orleans Musicians’ Clinic”. (Id.) While five providers in the Baton Rouge area are identified in the corrected Declaration, “LSU Health-OLOL” appears twice. (Id.) One location’s medical doctors do not accept new patients, and neither clinic provides contraception of any kind. (Id.) Finally, only one Baton Rouge center has an approximate wait time of less than one week (“1-3 days,- same day for est. pt.”). (Id) 4. Abandonment of First Termination Action and Commencement of the Second Termination Action On September 9, 2015, Defendant chose to' “rescind” her earlier at-will terminations. (Doc. 38 at 2.) On September 14, 2015, Defendant sent the First Termination Letters, one for each Agreement, to PPGC. (Doc. 38 at 4, 6, 8, 10; Doc. 46-1 at 18-36.) On September 15, 2015, Defendant followed these rescission letters with four new termination letters (“Second Termination Letters”). (Doc. 39 at 1; Doc. 46-1 at 37-49.) While the First Termination Letters had invoked Section 46:437.11(D)(1), (Doc. 38 at 4, 6, 8, 10), the Second Termination Letters rely on Sections 46:437.11(D)(2) and 46:437.14 and Title 50. (Doc. 39-1 at 2-3, 5-6, 8-9, 11-12; Doc. 46-1 at 37-49). Both MAPIL sub-provisions, Section 46:436.11(D)(2) allows for “for cause” termination of a provider agreement, and Section 46:437.14 identifies a number of violations, LA. R.S. §§ 46:437:11(D)(2), 46:437.14. The Second Termination Letters specify several different grounds. The first is a settlement in Reynolds v. Planned Parenthood Gulf Coast, Inc., Case Number 9:09-cv-124-RC (E.D; Tex.) (“Reynolds Settlement”), a lawsuit pursuant to the False Claims Act (“FCA”) in the Eastern District of Texas between PPGC and an FCA plaintiff. (Doc. 39-1 at 2, 5, 8, 11.) According to the letters, two violations of Title 50 were based on this settlement. First, simply by settling this action, PPGC had violated Title 50. (Id.) Second, since DHHS had not been informed “within ten (10) working days of when the provider knew or should have known of the violation,” another violation of Title 50 had occurred. (Id.) A second (or third) ground consisted of “provider audits and federal false claims cases against PPFA ... affiliates.” (Id.) Another Texas case, Carroll v. Planned Parenthood Gulf Coast, Case Number 4:12-cv-03505 (S.D. Tex.) (“Carroll”), fell within this description. According to the letters, in Carroll, “the presiding judge found that the information already provided allows the court to draw the reasonable inference that Planned Parenthood knowingly filed false claims.” '(Doc. 39-1 at 2, 5, 8, 11; see also Hr’g Tr. 36:2-22, Oct. 16, 2015.) Relying on this interpretation of Carroll, the Second Terminations Letters cite Louisiana law — “Providers and providers-in-fact are required to ensure that all their agents and affiliates are in compliance.with all federal and state laws as well as rules, policies and procedures of the Medicaid program” — and concluded: “PPGC and its parent organization PPFA has failed to do so and has failed to notify DHH of violations and misconduct by affiliates and providers-in-fact[,] ... violations of ... Title 50.” (Doc. 39-1 at 2, 5, 8, 11.) The third basis for termination was Defendant’s determination that PPGC’s July and August Letters, see swpra Part II.B, contained “misrepresentations” upon Defendant’s further review of CMP’s videos. (Doc. 39-1 at 3, 6, .9,. 12.) These alleged misrepresentations were described as violations of Sections 46:437.11(D)(2) and 46:437.14(A)(1). (Id.) Although other grounds are referenced in these letters, including audits, noncompliance with various Title 50 conditions, and more, unidentified misrepresentations constitute the third effective category. (Id.) After receiving these Second Termination Letters, Plaintiffs filed an unopposed motion to amend the complaint on October 7, 2015, (Doc. 41), a request granted on that same day, ,(Doc. 42).. Already attached to the motion to amend, (Doc. 41-1), a new amended complaint. (“Amended Complaint”) followed on October 7, 2015, (Doc. 43). Two days later, Plaintiffs filed the Renewed Motion for TRO, (Doc. 45), and the Renewed Memorandum, (Doe, 46). Simultaneously, Plaintiffs filed the Plaintiffs’ Motion for Limited Expedited Written Discovery, (Doc. 47), and Plaintiffs’ Memorandum in Support of Plaintiffs’ Motion for Limited Expedited Discovery, (Doc. 48). On October 14, 2015, Plaintiffs docketed the Memorandum Regarding Availability of . State Remedy. (Doc. 52 at 1.) Defendant filed the Motion to Dismiss, (Doc. 53), and Defendant’s Memorandum on October 14, 2015, (Doc. 53-1). On October 16, 2015, this Court held the Second Hearing. The Court orally denied Plaintiffs’ Mótion for Limited Expedited Written Discovery and took the remaining motions under advisement at' the Second Hearing’s conclusion. Late that day, Plaintiffs filed a copy of the Reynolds Settlement. (Doc. 54.) On Sunday, October 18, 2015, this Court issued an order denying Defendant’s motion to dismiss and granting Plaintiffs’ request for a temporary restraining order. (Doc. 55.) It set a status conference for the following day. (Id. at 59.) At that status conference, all parties agreed that no further discovery and no further argument was necessary for this Court to make its determination on whether to issue a preliminary injunction. (Doc. 58.) The Parties expressed “no objection to converting the temporary restraining order to a preliminary injunction.” (Id.) On October 28, 2015, Plaintiffs filed the Notice of Supplemental Authority. (Doc. 61.) The Notice includes as an attachment a copy of “a preliminary injunction,” issued by the Middle District of Alabama, “in a case substantially , similar to the instant action.” (Id. at 1.) Later that same day, at Defendant’s request, this Court held a second telephonic status conference. (Doc. 62.) Once more, the Parties affirmed that they regarded the record as complete and sufficient for the issuance of a preliminary injunction, (Id. ) D. OVERVIEW OF PARTIES’ ARGUMENTS 1. Plaintiffs’ Arguments In their Motion for TRO and Renewed Motion for TRO, Plaintiffs have made four relevant arguments to why they are entitled to a temporary restraining order. First, Plaintiffs contend that they will likely prove that Defendant’s efforts violate federal statutory' and constitutional law. They begin by arguing that Defendant’s latest termination, like the first, is prohibited by «the plain meaning of Section 1396a(a)(23) and are thus in' violation of controlling federal law. (Doc. 46 at 17-22; see also Doc. 4-1 at 16.) This Free-Choiee-of-Provider Provision bars Defendant from excluding PPGC from Medicaid for a rear son unrelated to its fitness to provide medical services. (Doc. 46 at 18, 21, 22; Doc. 4-1 at 11.) Because “Defendant has nowhere suggested that PPGC is not ‘qualified to perform’ the Medicaid services it provides,” its action cannot be cohered with this subsection’s language and purpose. (Doc. 4-1 at 15, 16; see also Doc. 46 at 17.) Plaintiffs concurrently maintain that this particular subsection, in contrast with Section 1396a(a)(30), which was the focus in Armstrong, does afford the Individual Plaintiffs with a right enforceable via Section 1983. (Doc. 46 at 18-19 & n.9; Doc. 4-1 at 12-13 & n.9; see also Hr’g Tr. 6:23-7:4, Sept. 2, 2015.) Throughout their discussion in the Renewed Memorandum, Plaintiffs rely on many of the 'same cases, including Planned Parenthood Ariz. Inc. v. Betlach, 727 F.3d 960 (9th Cir.2013), cert. denied, — U.S. -, 134 S.Ct. 1283, 188 L.Ed.2d 300 (2014) (“Betlach”); Planned Parenthood of Ind., Inc. v. Comm’r of Ind. State Dep’t of Health, 699 F.3d 962 (7th Cir.2012), cert. denied, — U.S. -, 133 S.Ct. 2738, 186 L.Ed.2d 193 (2013) (2013 (“Indiana”); and Women’s Hospital Foundation v. Townsend, No. 07-711-JJB-DLD, 2008 U.S. Dist. LEXIS 52549, 2008 WL 2743284 (M.D.La. July 10, 2008) (“Townsend”). (See, e.g., Doc. 46 at 17, 18 & 18 n.13.) Repeatedly, Plaintiffs emphasize that even if PPGC’s action would be barred by Armstrong the Individual Plaintiffs retain a viable cause of action under Section 1983. In the Renewed Memorandum, Plaintiffs do abandon their procedural due process claim, (Hr’g Tr. 15:19-16:1, Oct. 16, 2015; compare Doc. 43 ¶¶ 62-67 at 19-20, with Doc. 1 ¶¶ 56-57 at 14), but . do reiterate their two constitutional ones, (Doc. 1 ¶¶ 52-55 at 14; Doc. 43 ¶¶ 64-67 at 20). Now, Plaintiffs argue that Defendant, without sufficient justification, is singling them out for unfavorable treatment, violating the Equal Protection Clause of the Constitution’s Fourteenth Amendment, U.S. Const. amend. XIV, § 2, and is attempting to penalize them for freely associating with other related Planned Parenthood entities, thereby contravening the freedom' of association guaranteed by the First Amendment, see U.S. Const, amends. I, IX, § 2; Nat'l Ass’n for Advancement of Colored People v. Ala. ex rel. Patterson, 357 U.S. 449, 460, 78 S.Ct. 1163, 1170-71, 2 L.Ed.2d 1488 (1958); Arnaud v. Odom, 870 F.2d 304, 311 (5th Cir.1989). (See, e.g., Doc. 46 at 22.) ■ Second, Plaintiffs insist that the harm to PPGC and the Individual Plaintiffs will be irreparable if the termination comes to pass. The Individual Plaintiffs will be deprived- of their ability to exercise their federal statutory rights, and will- suffer a disruption of their relationship with a preferred (and competent) provider and a reduction of their access- to family planning services. (Doc. 46 at 26; see also Doc. 4-1 at 8-9, 17.) PPGC, in turn, will find its budget sharply curtailed, possibly forcing it to close down BRHC permanently, and will never be able to recover any monetary damages from DHH. (Doc, 46 at 27 & n.19; see also Doc. 4-1 at 17-18,18 ii.13.) Third, Plaintiffs argue that the balance of harms favors them. “While PPGC and its patients will suffer serious irreparable harm in the absence of an injunction, the state will suffer no injury at all.” (Doc. 46 at 27; see also Doc. 4-1 at 18.) The reason, Plaintiffs contend, is because an injunction will do no more than “require the state to maintain the funding [it] ha[s] provided to ... [PPGC] for years.” (Doc. 46 at 27 (internal quotation marks omitted) (alterations in original); see also Doc. 4-1 at 18.) Finally, Plaintiffs assert that the public interest favors their injunctive request. The public has a “strong” interest “in ensuring continued public access to crucial health services, especially for the. many underserved and low-income patients PPGC serves.” (Doc. 46 at 28; see also Doc. 4-1 at 18.) Such an interest is especially “acute with respect to the neediest ... who depend on publicly funded programs.” (Doc. 46 at 28; see also Doc. 4-1 at 19.) As to Defendant’s argument that PPGC’s failure to pursue a state administrative appeal of the termination renders the controversy not ripe and deprives all Plaintiffs of standing,' Plaintiffs argue that PPGC is not required to pursue the state administrative appeal but can instead pursue its rights under Section 1983. (Doc. 52 at 2-3; see also Hr’g Tr. 6:6-10, Sept. 2, 2015.) The Individual Plaintiffs argue that they have no right to administratively appeal the Agreements’ termination and thus could not do-so if they wanted to. (Doc. 52 at 3; see also Hr’g Tr. 10:15-17, Sept. 2, 2015.) As such, regardless of whether or not PPGC’s claims are ripe, their claims are clearly so, and their standing just as much. (See Doc. 52 at 1.) 2. Defendant’s Arguments Invoking Rule 12(b)(1) and (6), Defendant makes essentially. three arguments. First, Defendant contends that this Court lacks subject-matter jurisdiction over this dispute because this ease is not ripe and Plaintiffs lack prudential and constitutional standing. (Doc. 53-1 at 5-9.) Defendant insists on this case’s unripe state for three reasons: (1) “Plaintiffs, have suffered no injury”; (2) “further procedural and factual development is required”; and (3) no hardship can be shown. (Id. at 6, 8.) As support for his first and second reason, Defendant argues that because PPGC may appeal this termination, during which the Agreements will remain enforce in accordance with Defendant’s wishes, this "sus-pensive” review process - leaves all Plaintiffs without a cognizable injury. (Id. at 6-7 (injury), 8 (hardship), 9 (injury for standing purposes).) Defendant’s Memorandum further explains the reasons for a lack of ripeness and standing as such: “In the instant matter, PPGC is' asserting a due process' violation while simultaneously hinting that it may voluntarily elect not to participate in the process about which it complains.” (Id. at 8 (emphasis in original).) ■ Second, Defendant argues for abstention, emphasizing these doctrines’ purpose of “preserving] the balance between state and federal sovereignty.” (Id. at 10.) Defendant cites to four abstention doctrine— Pullman, Younger, Burford, and Colorado River — and foregoes one — Thibodaux. (Id. at 10-12.) When cumulatively (Considered, these doctrine’s “animating” principles have a “clear .., application” to this proceeding: “Plaintiffs should not be indulged in their attempt to invoke the jurisdiction of this Court in the absence of State agency action against them that would- delineate ... [Defendant’s] interpretation of the challenged provision-, and in the pres-enee of adequate state administrative and judicial procedures if that eventuality were to occur.” (Id. at 12.) Third, Defendant insists Plaintiffs cannot prevail on the merits for four reasons. First, “Plaintiffs have no property interest in the Medicaid provider contracts.” (Id. at 13; see also Doc. 13 at 14-18.) Second, even if Plaintiffs have a property interest, Louisiana’s administrative appellate process “complies with the mandates of due'process” and federal regulation, for “the essence of due process is notice plus an opportunity to be heard.” (Doc. 53-1 at 17.) Third, Defendant insists that Section 1396a(a)(23) does not afford the Individual Plaintiffs any private cause of action, (Compare Doc. 53-1 at 18-22, with Doc. 13 at .4-9), and is sufficiently ambiguous .to permit Defendant to exercise her discretion to define “qualified” in accordance with her construction of state law, (Doc. 53-1 at 21; see also Doc. 4 at 8). Defendant thus insists that her authority under Section 46:437.11(D)(2) is not limited “to determining whether a provider is competent to provide ... services.” (Doc. 53-1 at 22.) She can, instead, invoke any ground derived from state law, including, but not limited, the bases set forth in' Section 46:437.12 and Title 50, to determine whether a provider is “competent” or not. (Doc. 53-1 at 23-24.) IV. PRELIMINARY ISSUES: JURISDICTION AND ABSTENTION A. RIPENESS 1. Defendant’s Arguments Defendant provides the . correct standard by which to measure its argument that this case is not ripe: for the purposes of this doctrine, “a court must evaluate (1) the fitness of the issues for judicial resolution, and (2). the potential hardship to the parties by declining court consideration,” (Doc. 53-1 at 6 (quoting Lopez v. City of Houston, 617 F.3d 336, 342 (5th Cir.2010)). Defendant maintains the case is not ripe for three reasons: (1) “Plaintiffs have suffered no injury”; (2) “[F]urther procedural and factual development is required, as demonstrated by Plaintiffs’ due process claim ... and their request to conduct expedited discovery in this proceeding”; and (3) no hardship exists because “the review process is suspen-sive,” a third point substantively identical to its first (Doc. 53-1 at 6, 8). At the Second Hearing, her counsel stressed one aspect of the Constitution’s ripeness requirement: “There is absolutely no injury”; “[Tjhere is absolutely no harm to them at aii’v “[Tjhey have no injury”; and, “There’s no concrete injury to any of the Planned Parenthood or to any of the Jane Doe Plaintiffs because, again, there simply is ho injury.” (Hr’g Tr. 4:21-23, 9:2, 17:18-21, Oct. 16, 2015.) 2. Analysis (a) Existence of Credible Threat of Concrete Harm Drawn from Article III but incorporating various prudential elements, U.S. Const. art. III, § 2; Reno v. Catholic Soc. Servs., Inc., 509 U.S. 43, 57 n. 18, 113 S.Ct. 2485, 2495 n. 18, 125 L.Ed.2d 38 (1993), ripeness is “a justiciability doctrine designed to prevent the courts, through avoidance of premature adjudication, from entangling themselves in abstract disagreements over administrative policies, and also to protect the agencies from judicial interference until an administrative decision has been formalized and its effects felt in a concrete way by the challenging parties,” Nat'l Park Hospitality Ass’n v. U.S. Dep’t of Interior, 538 U.S. 803, 807-08, 123 S.Ct. 2026, 2030, 155 L.Ed.2d 1017 (2003) (internal quotation marks omitted). It generally incorporates, as Defendant rightly notes, (Doc. 53-1 at 6), consideration of two elements: “(1) the fitness of the issues for judicial decision and (2) the hardship to- the parties of withholding court consideration.” Nat’l Park Hospitality Ass’n, 538 U.S. at 808, 123 S.Ct. 2026 (citing to Abbott Labs. v. Gardner, 387 U.S. 136, 149, 87 S.Ct. 1507, 1515, 18 L.Ed.2d 681 (1967) (“Abbott Labs.”), overruled on other grounds, Califano v. Sanders, 430 U.S. 99, 105, 97 S.Ct. 980, 984, 51 L.Ed.2d 192 (1977))). Defendant argues that Plaintiff has suffered no injury sufficient for ripeness’ purposes. This argument fails for two reasons. The primary reason is well-rooted in ripeness jurisprudence: “In evaluating ripeness, the central focus is on whether the case involves uncertain or contingent future events that may not occur as anticipated, or indeed may not occur at all.” Tarrant Reg’l Water Dist. v. Herrmann, 656 F.3d 1222, 1250 (10th Cir.2011) (quoting Initiative & Referendum Inst. v. Walker, 450 F.3d 1082, 1097 (10th Cir. 2006)). However, an injury need not be actual in a physical sense for a plaintiffs case to cross the ripeness threshold. Rather, if a plaintiff is “immediately in danger of sustaining some direct injury as the result of the challenged official conduct,” ripeness will often be found. Pearson v. Holder, 624 F.3d 682, 684 (5th Cir.2010); see also Whole Woman’s Health v. Cole, 790 F.3d 563, 582 (5th Cir.2015) (quoting id.). It is enough that “an injury that has not yet occurred is sufficiently likely to happen to justify judicial intervention” or “when the court would be in no better position to adjudicate the issues in the future than it is now.” Pearson, 624 F.3d at 684 (quoting City of Los Angeles v. Lyons, 461 U.S. 95, 101-02, 103 S.Ct. 1660, 1665, 75 L.Ed.2d 675 (1983)). A “future injury” will be deemed ripe (and establish standing) if either “the injury is certainly impending” or “there is substantial risk that the harm will occur:” Susan B. Anthony List v. Driehaus, — U.S. -, 134 S.Ct. 2334, 2341, 189 L.Ed.2d 246 (2014) (emphasis added); see also Caprock Plains Fed. Bank Ass’n v. Farm Credit Admin., 843 F.2d 840, 845 (5th Cir.1988) (concluding that “too, many ifs” that render an injury a “mere potentiality],” not just one or two that may render such a result into a substantial possibility or even a probability, will make a case unripe). Thus, “ripeness is seldom'an obstacle to a pre-enforcement challenge ... where the plaintiff faces a credible” threat of enforcement.” Consumer Data Indus. Ass’n v. King, 678 F.3d 898, 907 (10th Cir.2012); cf. Babbitt v. UFW Nat’l Union, 442 U.S. 289, 298, 99 S.Ct. 2301, 2308, 60 L.Ed.2d 895 (1979) (finding standing where “a realistic danger of sustaining a direct injury as 'a result of a statute’s operation or enforcement” existed (emphasis added)). In such cases, the plaintiff is typically “not ... required to await and undergo [enforcement] as the sole means of seeking relief.” Consumer Data, Indus. Ass’n, 678 F.3d at 907; see also, e.g., Barrick Goldstrike Mines, Inc. v. Browner, 215 F.3d 45, 49 (D.C.Cir.2000) (holding that declaratory judgment action was ripe for judicial review under the Administrative Procedures Act where plaintiffs “only alternative to obtaining judicial review now is to violate EPA’s directives ... and then defend an enforcement proceeding on the grounds it raises here”). As. the Supreme Court has recently written, an agency’s prospective, not yet consummated, action will be found ripe for review if “the scope of the controversy has been reduced to more manageable proportions ... by some concrete action applying the regulation to the claimant’s situation in a fashion that harms or threatens to harm, him.” Nat’l Park Hospitality Ass’n, 538 U.S. at 808, 123 S.Ct. 2026 (emphasis added). Under this precedent, Defendant’s Second Termination Letters represent certain threats, classifiable as “concrete aetion[s]” that “threaten to harm” Plaintiffs, id.; see also Alabama-Coushatta Tribe of Tex. v. United States, 757 F.3d 484, 491 (5th Cir. 2014). Here, -the existing record amply supports this determination: Defendant has made it clear she intends to terminate the Agreements, the only thing changing since the initial termination letters being the reason. In effect, by her own actions, she has triggered the application of a general rule, federal courts having “consistently found a case or controversy in suits between state officials charged with enforcing a law and private parties potentially subject to enforcement,” Consumer Data Indus. Ass’n, 678 F.3d at 905. A case’s ripeness simply does not depend on whether the injury has already been inflicted; “specific threat[s] of enforcement” like those the Defendant has already made are typically more than enough to satisfy the constitutional minimum. Reynolds v. City of Valley Park, No. 4:06CV01487 ERW, 2006 U.S. Dist. LEXIS 83210, at *25, 2006 WL 3331082, at *6,(E.D.Mo. Nov. 15, 2006); see also, e.g., Cass Cnty. v. United States, 570 F.2d 737, 740 (8th Cir. 1978) (“Basically, the question in each case is whether the facts alleged, under all the circumstances, show that there is a substantial controversy, between parties having adverse legal interests, of sufficient immediacy and reality to warrant the issuance of a declaratory judgment.” (quoting Maryland Cas. Co. v. Pac. Coal & Oil Co., 312 U.S. 270, 273, 61 S.Ct. 510, 512, 85 L.Ed. 826 (1941)). In this analysis, Defendant’s own description of her actions is pivotal and telling. She has not proposed a new regulation or initiated a new round of rulemaking. (See, e.g., Hr’g Tr. 33:11-14, Oct. 16, 2015; Doc. 53-1 at 1-2.) Instead, per her Second Terminations Letters, she intends to enforce what she perceives to be state law in accordance with her construction of federal statutory law. (Doc. 39-1 at 2-3, 5-6, 8-9, 11-12.) In fact, as the First Termination Letters attest, the Agreements’ termination pursuant to a MAPIL section has been threatened since at least August 2015, and Defendant has now only swapped no reason for three. (Compare Doc. 13, with Doc. 39-1.) As such, in the Tenth Circuit’s words, “enforcement” has been “credib[ly] threatened],” her actions having made Plaintiffs’ case ripe by lending substance to their pre-October 18, 2015, allegations. Consumer Data Indus. Ass’n v. King, 678 F.3d at 907. In such a situation, “[o]ne does not have to await the consummation of threatened injury to obtain preventive relief,” for “the injury is certainly impending” — and “that is enough.” Pac. Gas & Elec. Co. v. State Energy Res. Conservation & Dev. Comm’n, 461 U.S. 190, 201, 103 S.Ct. 1713, 1721, 75 L.Ed.2d 752 (1983) (quoting Pennsylvania v. West Virginia, 262 U.S. 553, 593, 43 S.Ct. 658, 663, 67 L.Ed. 1117 (1923)). Based on these circumstances and the overwhelming weight of precedent, Plaintiffs’ threatened and certain injury is clear. Two general admissions by Defendant’s counsel at the Second Hearing strengthen this conclusion. First, though only indirectly, . he himself conceded that a kind of “harm” may have already come to pass: in arguing why no cognizable injury had yet transpired, he emphasized possible contingencies: “I think that one of the contingencies that could happen is their rights could be restored — [The] suspension could be lifted.” (Hr’g Tr. 17:23-25, Oct. 16, 2015 (emphases added).) He characterized Defendant’s actions as, prior to October 18, 2015, being “suspensive” if PPGC chose to appeal, and “the final action” as “suspended.” (Hr’g Tr. 10:4-12, 6:1-6, Oct. 16, 2015.) Both the First and Second Termination Letters imply the same. (Doc. 38 at 4, 6, 8, 10 (informing PPGC that DHH “will be notifying you by separate communication of an exclusion/termination/revocation from the Louisiana Medicaid program for cause” and describing PPGC as possessing “rights to a suspensive appeal” of this “exclusion/revocation/termination” (emphasis added)); Doc. 46-1 at 41, 44,. 47, 51 (“[Y]ou are hereby notified that the Department of Health and Hospitals (DHH) is hereby terminating I revoking the PPGC provider agreement referenced above. This action will take effect ____” (emphases added)).) This highlighted language implies that Plaintiffs’ rights have already been curtailed, a suspension already imposed, and the relevant action, i.e. the Agreements’ termination, already undertaken, its “effect” alone delayed. Any one of these imputations would constitute a sufficiently credible threat to render this case ripe. Later, moreover, Defendant’s counsel unambiguously confirmed these statements’ implications. To the Court’s question — “the Secretary has terminated the contract, but ... has said that termination is suspended pending appeal?” — he answered: “That’s correct.” (Hr’g Tr. 19:16-19, Oct. 16, 2015; see also Doc. 53-1 at 9-10.) Thus, even if the termination is suspended, it will occur automatically but for this Court’s intervention. That its practical enforcement may be stayed does not change the key fact: using Pearson’s terms, Plaintiffs are in “danger of sustaining some direct injury as the result of the challenged official conduct,” Pearson, 624 F.3d at 684. A final exchange cinches this conclusion. When Plaintiffs’ counsel revealed PPGC’s intent “to proceed in federal court” and not “to pursue the administrative remedy,” and the Court observed, “Well, then it seems to me you’ve got a very, very ripe situation,” and asked Defendant’s counsel, “Am I missing something on that?” he answered, “No.” (Hr’g Tr. 20:18-23, Oct. 16, 2015.) Equally worthy of note, Defendant quotes but dismisses the import of a principle embedded in ripeness case law: “[A] case is generally ripe if any remaining questions are purely legal ones,” Lopez, 617 F.3d at 341. This principle holds even if “the application of the disputed rule [or the ultimate decision] remains within the agency’s discretion.” Nat’l Ass’n of Home Builders v. U.S. Army Corps of Eng’rs, 417 F.3d 1272, 1282 (D.C.Cir.2005); see also Nat’l Treasury Emps. Union v. Chertoff, 452 F.3d 839, 854 (D.C.Cir.2006) (citing id. and finding ripeness when “waiting to observe” an agency’s final “actions would only exacerbate the ... asserted injury while doing nothing to enable judicial review”). In this context, a truly nonlegal question, notably, is often one whose resolution is necessarily “reliant on” and demands “agency expertise.” Marcum v. Salazar, 694 F.3d 123, 129 (D.C.Cir.2012). As any fair reading of the complaint and motions filed in this case indicates, the issue involves at least one, if not three, “purely ... legal question[s]”: the precise meaning of Section 1396a(a)(23) and the applicability of two constitutional clauses. (See, e.g., Doc. 1 at 1; Doc. 43 at 1.) In Abbott Labs., the seminal case in ripeness jurisprudence, the Court concluded that the issues presented were appropriate for judicial resolution because the facial challenge to the regulation involved the purely legal question of whether the regulation at issue exceeded the scope permitted by the underlying statute. See Abbott Labs., 387 U.S. at 149, 87 S.Ct. 1507. This kind of challenge, found ripe in Abbott Labs., resembles the challenge that PPGC now makes, with “consideration of the, underlying legal issues” not “necessarily be[ing] facilitated if they were raised in the context of a specific attempt to [apply and/or] enforce the regulations,” Gardner v. Toilet Goods Ass’n, 887 U.S. 167, 171, 87 S.Ct. 1526, 1528, 18 L.Ed.2d 704 (1967). “Predominantly legal questions” like a statute’s plain meaning and whether a person’s conduct contravenes its unambiguous^ command are nearly always ripe. See, e.g., Fla. State Conf. of the NAACP v. Browning, 522 F.3d 1153, 1164 (11th Cir.2008) (“The Supreme Court has long since.held that where the enforcement of a statute is certain, a preenforcement challenge will not be rejected on ripeness grounds.”); Nat’l Ass’n of Home Builders, 417 F.3d at 1282 (“Claims that an agency’s action is arbitrary and capricious or contrary to law present purely legal issues.”); cf. LeClerc v. Webb, 419 "F.3d 405, 414 (5th Cir.2005) (noting that “actions for declaratory relief ... by design permit pre-enforcement review” and applying two exceptions). Plaintiffs’ present action presents precisely such questions. (b) Existence of Requisite Hardship The jurisprudence construing the hardship requirement is just as clear. The Fifth Circuit “has found hardship to inhere in legal harms, such as the harmful creation of legal rights or obligations; practical harms on the interests advanced by the party seeking relief; and the harm of being force[d] ... to modify [one’s] behavior in order to avoid future adverse consequence.” Choice Inc. v. Greenstein, 691 F.3d 710, 715 (5th Cir.2012) (alteration in original) (internal quotation marks omitted). Discrete formulations, a plaintiff can meet the ripeness doctrine’s hardship prong by satisfying just one. Id. As the Court’s decisions clarify, the first test has been met when an agency proposes to “grant, withhold, or modify any formal legal license, power or authority,” Ohio Forestry Ass’n v. Sierra Club, 523 U.S. 726, 733, 118 S.Ct. 1665, 1670, 140 L.Ed.2d 921 (1988), and the second is fulfilled when “the impact of the administrative action could be said to be felt immediately by those subject to it in conducting their day-to-day affairs,” Toilet Goods Ass’n v. Gardner, 387 U.S. 158, 164, 87 S.Ct. 1520, 1524, 18 L.Ed.2d 697 (1967). Quite simply, Defendant’s conduct here cannot be described in any different terms. Since a threat suffices to satisfy ripeness’ hardship requirement, to conclude differently would, be to find no case ripe when an administrative option remains for one of many plaintiffs and a statutory right and remedy exists for all, a result contrary to the many opinions that’ have confronted claims under Section 1396a(a)(23). See infra Part V; see also, e.g., Sab