Full opinion text
AMENDED MEMORANDUM OF DECISION AND ORDER LEVI, District Judge. Plaintiffs are providers and recipients or potential recipients of Medi-Cal funded drug abuse treatment services. Plaintiffs claim that the State of California is administering its federally funded Medi-Cal drug abuse program under an administrative and statutory scheme that fails to comply with the requirements of Title XIX of the Social Security Act, 42 U.S.C. §§ 1396 et seq. (the “Medicaid Act”). In particular, plaintiffs object to the State’s practice of allowing the counties to determine whether and in what amount to provide Medi-Cal funded methadone maintenance treatment services. Plaintiffs contend that as a result of this system methadone maintenance is wholly unavailable under Medi-Cal for residents of some California counties. Moreover, in counties where treatment is available, plaintiffs aver that the level of service provided is insufficient to meet the need and that patients are placed on waiting lists for Medi-Cal funded “treatment slots.” In contrast, other Medi-Cal covered services are available upon presentment of a MediCal card to a licensed provider. Plaintiffs seek injunctive relief through this action brought under 42 U.S.C. § 1983. This Amended Memorandum of Decision and Order, issued upon plaintiffs’ further motion for summary judgment and motion for reconsideration, supersedes the court’s previous opinion of October 26, 1993. I. Background The federal Medicaid program provides federal funds to states to pay for medical treatment for the needy. Schweiker v. Gray Panthers, 453 U.S. 34, 36, 101 S.Ct. 2633, 2636, 69 L.Ed.2d 460 (1981). State participation is optional, but states that choose to participate must submit a state plan that fulfills the requirements of the Medicaid Act. 42 U.S.C. § 1396a(b). For a state plan to be approved, the plan must comply with 58 conditions set forth in 42 U.S.C. § 1396a(a). California has elected to participate in the federal Medicaid program through its California Medical Assistance Program, known as “Medi-Cal,” which provides medical services to the aged, disabled, and indigent. Citizens Action League v. Kizer, 887 F.2d 1003, 1005 (9th Cir.1989), cert. denied, 494 U.S. 1056, 110 S.Ct. 1524, 108 L.Ed.2d 764 (1990); Cal.Welf. & Inst.Code §§ 14000-14196. Federal law does not require that states provide methadone maintenance services in their Medicaid plans. It is an optional service. But once a state elects to provide an optional service such as methadone maintenance, that service becomes part of the state Medicaid plan and is subject to the requirements of federal law. Weaver v. Reagen, 886 F.2d 194, 197 (8th Cir.1989); Eder v. Beal, 609 F.2d 695, 701-02 (3d Cir.1979); Clark v. Kizer, 758 F.Supp. 572, 575 (E.D.Cal.1990), aff'd in part and vacated in part on other grounds sub nom., Clark v. Coye, 967 F.2d 585 (9th Cir.1992) (table); see also King v. Smith, 392 U.S. 309, 316, 88 S.Ct. 2128, 2133, 20 L.Ed.2d 1118 (1968). Methadone maintenance is one of several drug abuse treatment services offered as part of California’s “Drug/Medi-Cal” program. Cal.Welf. & Inst.Code §§ 14021(c), 14021.5 & 14131; Cal.Code Regs. tit. 22, § 51341; Dep. of Venus Little, 34:24-35:1. Medi-Cal is generally administered on a “fee-for-service” basis by the California Department of Health Services. To receive services, Medi-Cal recipients present Medi-Cal cards to certified providers of authorized treatments or services. Cal.Welf. & Inst. Code § 14018; Cal.Code Regs. tit. 22, §§ 50731 & 50733(a); see also Defs.’ Statement of Material Facts, ¶ 7. The provider then bills the State a pre-established fee for that service. Defs.’ Statement of Material Facts, ¶ 8. The Medi-Cal card is “authorization for payment for Medi-Cal covered services received in any California county.” Cal.Code Regs. tit. 22, § 50735(a). In the fee-for-service scheme, the counties’ role is primarily to determine recipients’ eligibility in accordance with State regulations. Id. § 50101. Methadone maintenance is a method of treating dependence on opiates, including heroin. Methadone is a synthetic drug that relieves the symptoms of opiate withdrawal, and is itself addictive. Maintenance treatment includes prescription of methadone under medical supervision, drug screening, therapy, and vocational and substance abuse counselling. 21 C.F.R. §§ 291.505(a)(2) & 291.505(d)(4)(i)(A); Cal.Health & Safety Code § 11880. The ultimate goal of the treatment is to eliminate all dependence on drugs. Id. § 11880. Methadone maintenance providers are licensed for a maximum treatment capacity (called “treatment slots”) by the California Department of Alcohol and Drug Programs (the “Department of Alcohol and Drug Programs” or the “Department”) which acts after receiving a recommendation from the county in which the provider seeks to operate. Id. § 11877; Cal.Code Regs. tit. 9, §§ 10026, 10040 & 10045; Decl. of Joy Jarfors, ¶3. No provider may treat more than 300 patients at a time. Cal.Code Regs, tit. 9, §§ 10026(b) & 10145(b). To receive treatment, patients must meet federal and state eligibility criteria, for example, patients must have a documented history of at least two years of narcotic addiction. 21 C.F.R. § 291.505(d); Cal.Code Regs. tit. 9, § 10174. California’s Medicaid plan governing the provision of drug abuse treatment services consists of an interagency agreement between the Department of Health Services and the Department of Alcohol and Drug Programs. See Defs.’ Ex. 1. Under the agreement, provision of Medi-Cal funded methadone maintenance treatment is integrated into California’s separate statutory scheme governing drug abuse services. The key feature of California’s drug abuse scheme is that services are administered through locally controlled community drug abuse programs, in which each individual county is vested with the discretion to determine the appropriate mix and level of drug abuse services needed in the community. Cal.Health & Safety Code § 11960; Defs.’ Opp’n to first Summ.J.Mot. at 9-10. Each county may, but is not required to, seek funds allocated by the Department of Alcohol and Drug Programs for the purpose of alleviating drug abuse problems within its jurisdiction. Cal.Health & Safety Code § 11981. The Department annually estimates the total amount of State and federal funds available to each county for drug abuse services. Id. § 11983. Each county then prepares its own drug program plan, subject to State approval, which specifies the particular amount and type of drug abuse services which will be offered in that county. Id. §§ 11983.2 & 11983.1. Counties may choose to include any of the Drug/Medi-Cal services, including methadone maintenance, in their plans. If they do, State “matching” funds for the Drug/ Medi-Cal services are deducted from the State general fund monies already allocated to the county for its drug programs. Id. § 11987.3. If the county chooses not to include Drug/Medi-Cal services in its plan, then all of the State géneral fund monies allocated to the county are available for other services specified in the county’s drug program plan. Id. §§ 11987.3 & 11987.4; see also Dep. of Dana Kueffher, 30:14-35:15; Dep. of Robert Lefldn, 40:11^47:5, 48:24-49:14. Based on the amount of money allocated in the county plan to methadone maintenance, the counties contract with methadone maintenance providers for a specific dollar amount of treatment services, which in turn translates into a number of available MediCal funded “treatment slots.” Cal.Welf. & Inst.Code § 14021(c); Deck of Donald Nikkei, ¶¶ 5-7; Kueffner Dep., 53:1-55:5. As a result of this system, Medi-Cal methadone maintenance services are available only in those California counties that elect to receive Medi-Cal funds for that purpose. Defs.’ Statement of Disputed Facts, ¶ 14. Only 18 of the 58 counties in California have elected to fund Medi-Cal methadone maintenance. Def. Molly Joel Coye’s Resp. to Pis.’ Second Set of Interrogs., No. 4. In all but eight of the non-participating counties, there is no certified methadone maintenance provider for either Medi-Cal recipients or private pay patients. Jarfors Deck, ¶7. In the eight—-which includes Sonoma, San Diego, Ventura, Santa Barbara, Kern, and San Luis Obispo Counties—certified methadone maintenance providers serve private pay patients and patients subsidized under other programs, such as federal block grants, but do not receive any funding through MediCal. Lefkin Dep., 49:5-14, 50:10-13. If a county does not provide Medi-Cal methadone maintenance services, or if the county provides the service but the available “slots” are filled, then a Medi-Cal eligible individual cannot receive the service in that county under Medi-Cal. Little Dep. at 27-29, 47. Although the practice is contrary to State policy, see Pis.’ Ex.' 18, at least two counties include clauses in their provider contracts prohibiting providers from serving Medi-Cal patients who reside in other counties. Decl. of Brian Slattery, ¶ 7; Dep. of Richard Earle Brown, Jr., 30:21-31:2, 43:22, 65:5-66:7, 111:10-19. Plaintiffs have established that some methadone maintenance providers receive an insufficient number of treatment slots to serve all the Medi-Cal eligible in need of treatment; in response, some providers have created waiting lists for the Medi-Cal funded slots. Nikkei Deck, ¶¶8, 9, 11; Slattery Deck, ¶ 10; Kueffner Dep., 100:13-101:6; Dep. of Reda Z. Sobky, 35:1-6, 37:23-38:1. Plaintiffs also have submitted declarations from several Medi-Cal eligible methadone maintenance patients who are unable to obtain Medi-Cal services because of their county of residence, or who were obtaining services but were terminated from Medi-Cal funded treatment slots du& to insufficient Drug/ Medi-Cal funding. Decís, of Douglas Lip-man, Vicki Manahl, Sharon McCloud, Lisa Quilling, Terri Randall, Heather Randolph, Paul Sanchez, Jodi Sollenberger. These persons are “categorically needy” within the meaning of 42 U.S.C. § 1396a(a)(10)(A) because they receive Aid to Families with Dependent Children (“AFDC”) or because they receive SSL See id. Unlike other categorically needy persons and some “medically needy” individuals who receive methadone maintenance treatment through Medi-Cal, see Deck of Anne Bolla; Second Deck of Amitai Schwartz (incorporating letter from Ron Kletter), these members of the plaintiff class must either privately pay for methadone maintenance or forego treatment while they wait for Medi-Cal funded treatment slots to become available. As a result, they have suffered consequences such as homelessness, exposure to disease, medical complications resulting in hospitalization, and the risk of probation revocation. Decís, of Douglas Lipman, Vicki Manahl, Sharon McCloud, Lisa Quilling, Terri Randall, Heather Randolph, Paul Sanchez, Jodi Sollenberger; see also Slattery Deck, ¶ 13; Deck of Ronald K. Perry. Plaintiffs assert that the State’s scheme for providing Medi-Cal funded methadone maintenance treatment violates six requirements of the Medicaid statute: (1) the State’s Medicaid plan must be in effect statewide, 42 U.S.C. § 1896a(a)(1); (2) payments to providers must be sufficient so that Medi-Cal recipients receive comparable services as the general population in the geographic area, id. § 1396a(a)(30); (3) the State’s Medicaid plan must provide medical assistance to categorically needy individuals that is equal in amount, duration, and scope to the assistance provided to other categorically needy persons and at least equal in amount, duration, and scope to the assistance provided to medically needy persons, id. § 1396a(a)(10)(B); (4) each service must be sufficient in amount, duration, and scope to reasonably achieve its purpose, 42 C.F.R. § 440.230(b); (5) the plan must be administered or supervised by a single state agency, 42 U.S.C. § 1396a(a)(5); and (6) medical assistance under the plan must be furnished to all eligible individuals with reasonable promptness, id. § 1396a(a)(8). Plaintiffs seek summary judgment on these claims, or in the alternative, a preliminary injunction invalidating the State scheme. Defendants seek to dismiss both the Sobky and Merritt complaints in their entirety. Defendants assert that plaintiffs have no right of action under 42 U.S.C. § 1983 to enforce the Medicaid plan requirements of the Social Security Act against the State. Further, defendants seek either summary judgment or dismissal as to plaintiffs’ claim asserting a violation of due process. II. Jurisdiction Relief under 42 U.S.C. § 1983 is not limited to federal constitutional violations but also may be based on violations of a federal statute. Maine v. Thiboutot, 448 U.S. 1, 6-8, 100 S.Ct. 2502, 2505-06, 65 L.Ed.2d 555 (1980). But because § 1983 is addressed to the deprivation .of “rights, privileges or immunities” and not merely the violation of federal law, a plaintiff must show that the federal law violated creates enforceable rights within the meaning of § 1983. Golden State Transit Corp. v. City of Los Angeles, 493 U.S. 103, 106, 110 S.Ct. 444, 448, 107 L.Ed.2d 420 (1989). The two most recent Supreme Court decisions addressing whether a statutory provision creates enforceable rights, Wilder v. Virginia Hosp. Ass’n, 496 U.S. 498, 110 S.Ct. 2510, 110 L.Ed.2d 455 (1990), and Suter v. Artist M., — U.S.-, 112 S.Ct. 1360, 118 L.Ed.2d 1 (1992), have led to a degree of uncertainty because of their varying approaches. In Wilder, 496 U.S. at 509-10, 110 S.Ct. at 2517, the Court found that § 1396a(a)(13) of the Medicaid Act—which requires a state Medicaid plan to provide for “reasonable rates” of payment for services— created a right enforceable by health care providers against the State under § 1983. Wilder applied the analytical framework first set out in Golden State. Under this framework, whether an enforceable federal right exists depends, first, on whether the statute in question is “intended to benefit” the plaintiff seeking to enforce it. Wilder, 496 U.S. at 509, 110 S.Ct. at 2517. If so, then the provision creates an enforceable right unless it merely expresses a “congressional preference” rather than a binding, mandatory obligation on the state, or unless the interest the plaintiff asserts is “ ‘too vague and amorphous’ such that it is ‘beyond the competence of the judiciary to enforce.’” Id. (quoting Pennhurst State Sch. & Hosp. v. Halderman, 451 U.S. 1, 19, 101 S.Ct. 1531, 1541, 67 L.Ed.2d 694 (1981); Golden State, 493 U.S. at 108, 110 S.Ct. at 449). With little or no discussion of jurisdictional issues, a succession of courts, in cases pre-dating Suter (and many even pre-dating Wilder), have routinely permitted beneficiary and provider actions under § 1983 to enforce various sections of the Medicaid Act. See, e.g., King v. Sullivan, 776 F.Supp. 645 (D.R.I.1991); Clark v. Kizer, 758 F.Supp. 572 (E.D.Cal.1990), aff'd in part and vacated in part on other grounds sub nom., Clark v. Coye, 967 F.2d 585 (9th Cir.1992) (table); Linton v. Carney, 779 F.Supp. 925 (E.D.Tenn.1990); Morgan v. Cohen, 665 F.Supp. 1164 (E.D.Pa.1987); Kessler v. Blum, 591 F.Supp. 1013 (S.D.N.Y.1984); Christy v. Ibarra, 826 P.2d 361 (Colo.1991). In Suter, — U.S. at -, 112 S.Ct. at 1370, the Court held that child beneficiaries of the Adoption Assistance and Child Welfare Act (the “Adoption Act”) could not enforce the requirement that the states use “reasonable efforts” to keep children in their homes. Without explicit reference to the Golden State/Wilder approach, the Court returned to its emphasis in Pennhurst, 451 U.S. at 17, 101 S.Ct. at 1540, that when legislation is enacted under Congress’ spending power, conditions imposed on the grant of federal money must be expressed “unambiguously.” After Suter, the critical inquiry focuses on the specificity of the statutory language; the court must “examine exactly what is required of States” by the enactment. Suter, — U.S. at-, 112 S.Ct. at 1367. Enforceable federal rights may be found when the statute and any implementing regulations “set forth in some detail” what the state must do to comply, but not when the method of compliance is left “within broad limits” to the state itself. Id. at-, 112 S.Ct. at 1368. The only unambiguous condition that the Adoption , Act placed on the states was to require a plan approved by the Secretary “containing] 16 listed features,” including the requirement for the states to use “reasonable efforts” to maintain children in their own homes. Id. at-, 112 S.Ct. at 1367. But the “reasonable efforts” feature itself “impose[s] only a rather generalized duty on the State,” a duty not specific enough to qualify as a privately enforceable right. Id. at--, 112 S.Ct. at 1370. Significantly, as has been repeatedly recognized in the case law, Suter neither overruled Wilder nor replaced the Wilder/Golden State framework with a different one. See, e.g., Stowell v. Ives, 976 F.2d 65, 68 (1st Cir.1992). Yet in arguing that the only right enforceable by plaintiffs under § 1983 is to a state plan approved by the Secretary, defendants suggest an application of Suter which is at odds with the holding of Wilder. Admittedly, when read alone, Suter can be interpreted as holding that when a statute requires submission of a state plan in order to obtain federal funds, a plaintiff has no cause of action under § 1983 beyond an action to require the submission of a conforming plan. See Suter, — U.S. at-, 112 S.Ct. at 1367 (noting that “the Act does place a requirement on the States, but that requirement only goes so far as to ensure that the State have a plan”); see also Evelyn V., 819 F.Supp. at 193 n. 8 (referring to proposed legislation to reverse Suter to the extent it holds that the only enforceable requirement of a federal funding statute is for a state to adopt an approved plan). But such an interpretation would directly conflict with the holding in Wilder and with Wilder’s express rejection of the view that in the context of the Medicaid statute “the only right enforceable under section 1983 is the right to compel compliance with [ ] bare procedural requirements” such as the adoption of an approved plan. Wilder, 496 U.S. at 513, 110 S.Ct. at 2519. Until further guidance is forthcoming, Suter and Wilder must be reconciled on some other basis than that Suter silently overrules Wilder. See, e.g., Arkansas Medical Soc’y, Inc. v. Reynolds, 6 F.3d 519, 525 (8th Cir.1993); Stowell, 976 F.2d at 68, 71; Travelers Health Network of Louisiana v. Orleans Parish Sch. Bd., 842 F.Supp. 236, 240 (E.D.La.1994); Evelyn V., 819 F.Supp. at 194. When Suter and Wilder are read together, an amalgamated approach can be stated which is consistent with either decision. First, because they have not been repudiated, Golden State and Wilder still provide the basic framework in deciding whether an enforceable federal right exists under § 1983. Thus, the provision sought to be enforced must be “intended to benefit the putative plaintiff,” must be mandatory rather than hortatory, and must not be so vague as to be “beyond the competence of the judiciary to enforce.” Wilder, 496 U.S. at 509, 110 S.Ct. at 2517. This test should now be applied in light of Suter’s directive to focus on “exactly what is required of States” by the statute or statutory section sought to be enforced. See Evelyn V., 819 F.Supp. at 194. Moreover, in determining the precision and assertiveness of the statutory language, Suter suggests that it is appropriate to consider: (1) the language in the context of “the entire legislative enactment,” Suter, — U.S. at-, 112 S.Ct. at 1367; (2) the existence of regulations which provide guidance to the states concerning the method or manner of compliance, id. at-, 112 S.Ct. at 1368; (3) whether the statutory directive is one “whose meaning will obviously vary with the circumstances of each individual case,” id.; (4) the availability of other mechanisms to enforce the statute, id.; and (5) the applicable legislative history, id. at-, 112 S.Ct. at 1369. Each of the six provisions of the Medicaid Act plaintiffs seek to enforce must be individually examined in light of the above approach to determine if a cause of action exists under § 1983. III. Violations of the Medicaid Act and Regulations A. In Effect Statewide Plaintiffs claim that the State’s scheme for providing Medi-Cal methadone maintenance treatment violates the requirement for statewide applicability of Medicaid plans set forth in 42 U.S.C. § 1396a(a)(1): “A State plan for medical assistance must ... provide that it shall be in effect in all political subdivisions of the State, and if administered by them, be mandatory upon them.” 1. Jurisdiction. Section 1396a(a)(1) creates a federal right enforceable by plaintiffs under § 1983. To begin with, the section is intended to benefit plaintiffs. While it makes no direct reference to Medicaid recipients, recipients of medical services are the obvious beneficiaries of a requirement that a medical assistance plan be in effect statewide. Further, that recipients are the intended beneficiaries is evident in the regulation implementing the section, found at 42 C.F.R. § 431.50. Because the regulation addresses “equitable standards of assistance” and “furnishing of] service,” its purpose is to ensure that Medi-Cal patients receive statewide access to services. See Part III.A.2 infra. Moreover, the section’s command to the states is mandatory, specific, and detailed. The statute requires that a state plan “must provide” for statewide application. The Suter Court found that nearly identical statutory language in the Adoption Act imposed mandatory standards on the states. Suter, — U.S. at -, 112 S.Ct. at 1367. The Court interpreted the language to require that “the plan apply to all political subdivisions of the State.” Id. at-, 112 S.Ct. at 1368. Further, the regulations define how service is to be furnished in order to achieve statewide operation and outline specific requirements, such as a system of local offices, procedures for equitable and uniform administration of policies, and systematic state evaluations. 42 C.F.R. §§ 431.50(b) & 431.-50(c). Given this level of guidance, the statewide requirement is within the competence of the judiciary to enforce. Finally, while the Medicaid Act gives the Secretary the authority to withhold federal funds from states failing to comply with 42 U.S.C. § 1396a(a), this alternative method of enforcement does not bar a § 1983 action. See Wilder, 496 U.S. at 512, 110 S.Ct. at 2519 (citing 42 U.S.C. § 1396c; 42 C.F.R. § 430.-35). This is true not only for the statewide requirement, but for all the plan provisions plaintiffs seek to enforce. In this respect, the Medicaid Act is distinguishable from the statute at issue in Suter. The Adoption Act not only called for loss of federal funds upon submission of a non-compliant plan, but also required an independent judicial determination before the states could be reimbursed for services associated with removing a child from his or her home. Suter, — U.S. at -, 112 S.Ct. at 1368. A similar additional enforcement mechanism is not available here. Accordingly, plaintiffs may bring suit under § 1983 to enforce the statewide requirement. 2. Merits. The parties contest the substance of the statewide requirement. Plaintiffs claim that the section entitles them to statewide access to Medi-Cal funded methadone maintenance services. Defendants argue, citing regulations at 42 C.F.R. § 431.-50(b), that § 1396a(a)(1) only requires states to provide statewide access to offices for eligibility determinations and other administrative processes. Defs.’ Opp’n to first Summ.J.Mot. at 8. Defendants’ argument, however, is misplaced in light of subsection (c) of the regulations. That subsection, by clarifying that not every individual provider must furnish services statewide, indicates that the furnishing of services is indeed encompassed within the requirement of “statewide operation” of the plan. See Clark v. Kizer, 758 F.Supp. 572, 580 (E.D.Cal.1990) (the “plain meaning of ‘be in effect’ would appear to be that the [Medi-Cal dental care] program shall be in existence, operational and functioning”), affd in part and vacated in part on other grounds sub nom., Clark v. Coye, 967 F.2d 585 (9th Cir.1992) (table); Morgan v. Cohen, 665 F.Supp. 1164, 1178 (E.D.Pa.1987) (the plan must “operate uniformly across the state”); Christy v. Ibarra, 826 P.2d 361, 364 (Colo.1991) (statewide requirement is violated where “services are available in some counties and not available in the neighboring counties”). Defendants further argue that the requirement for statewide operation, even if applicable to services, would only be violated if the State plan promised methadone maintenance for all who want or need it. Defs.’ Opp’n to first Summ.J.Mot. at 9 (relying on King v. Sullivan, 776 F.Supp. 645, 652 (D.R.I.1991) (“The State Plan must promise [the services sought] to Plaintiffs before the State’s failure to provide such services can constitute a violation of federal law.”)). Defendants claim that California’s plan promises only to provide those drug abuse treatment services selected by the counties as appropriate for the community; because residents in every county have access to some services—if not methadone maintenance, then methadone detoxification or drug free treatment—defendants argue that the plan applies statewide. This argument fails for a number of reasons. First, defendants’ reliance on King is misplaced. King does not involve the failure to provide any access to services in some parts of the State, but instead involves the State’s failure to provide the particular amount and type of service desired by plaintiffs. In King, the plaintiffs did not allege a violation of § 1396a(a)(1). Second, defendants’ interpretation goes a long way toward nullifying the statutory language. There is no practical difference between a plan which does not apply statewide and a plan which theoretically applies statewide but permits political subdivisions to decline to provide otherwise covered medical services. To permit states to offer different services in different political subdivisions, as long as the plan itself is procedurally applicable to every county, would result in a plan that is neither “in effect” nor operating on a statewide basis, if those terms have any meaning or purpose. See Wilder, 496 U.S. at 513, 110 S.Ct. at 2517 (the right to enforce a plan requirement is not “merely a procedural one”); see also Christy, 826 P.2d at 363-64. Third, defendants’ contention that a plan which does not require all political subdivisions to participate still may be deemed to apply statewide, so long as those counties which provide no services do so according to the plan, is directly-contradicted by the regulations. See 42 C.F.R. § 431.50(b)(1) (“The plan will be in operation statewide ... under equitable standards for assistance ... that are mandatory throughout the State.”). Finally, methadone maintenance is not distinguishable from other medical services once the State decides to treat it as a covered medical service under Medi-Cal. At oral argument, counsel for defendants suggested that methadone maintenance is analytically distinct from other medical treatment on the basis that drug treatment services contain a “large social component.” There may be some force to this argument as a matter of social policy. But there is no basis in the language of the Medicaid Act from which to derive an exception of drug treatment services from the statewide requirement. As a covered service, methadone maintenance is subject to the same requirements as any other medical service. Weaver v. Reagen, 886 F.2d 194, 197 (8th Cir.1989). Just as a Medicaid plan which provided residents of some counties access to heart by-pass operations to treat heart disease but residents of other counties access only to nutrition counseling and medication would violate § 1396a(a)(1), so does a plan that provides some residents methadone treatment and others, for example, only “day care habilitative treatment.” In short, a state scheme which denies access to a Medi-Cal covered medical treatment or service based on the recipient’s county of residence violates the requirement that the plan be in effect statewide. The remaining question is whether plaintiffs’ proof is sufficient to support the requested relief. As evidence that the plan is not in effect statewide, plaintiffs offer, first, the undisputed fact that only 18 counties have elected to receive Medi-Cal funding for methadone maintenance. The Chief Deputy Director of the Department of Alcohol and Drug Programs states that she believes there may be unmet need in the counties not providing Medi-Cal funded treatment. Dep. of Elizabeth Stanley, 31:14-22. Second, plaintiffs offer the testimony of two Santa Barbara County residents who are on public assistance but who must privately pay for methadone maintenance because that County does not offer Medi-Cal funded treatment. McCloud Decl., ¶ 3; Sanchez Deck, ¶ 3. Finally, the director of the Marin County clinic, which does receive Medi-Cal funds, states that he currently treats a Medi-Cal eligible patient from Lake County who must drive 180 miles each day to obtain treatment. He is unable to place her in a Medi-Cal funded slot because his contract with the County requires him to offer these slots to Marin residents only. Further, at his clinic, approximately 20 Medi-Cal patients are currently paying partial fees for service. Slattery Deck, ¶¶ 7, 8 & 9. In response, defendants offer evidence which indicates that Drug/Medi-Cal providers in several counties are in fact serving some out-of-county residents. Defs.’ Ex. 5, at 3. In addition, most of the 40 counties without Medi-Cal methadone maintenance lack a certified provider, so that treatment is unavailable in those counties even to private-pay patients. Jarfors Deck, ¶ 7. This evidence creates a factual dispute regarding whether Medi-Cal recipients in non-participating counties, as a class, are able to obtain services in other counties within a reasonable distance and a reasonable time. Plaintiffs have made a substantial evidentiary showing that the State scheme limits Medi-Cal coverage based on county of residence, and thereby have established a likelihood of success on the claim that access to services is unavailable statewide. Some questions remain, however, about the extent of the problem. The record does not reveal whether substantial numbers of the MediCal eligible are unable to obtain service under the current system, or instead whether only a handful of patients have slipped through the cracks. The lack of such evidence leaves the record insufficiently developed to grant summary judgment as to plaintiffs’ claim. See Irvin v. Griffin Corp., 808 F.2d 802, 807 (11th Cir.1987) (district court has wide discretion to deny a summary judgment motion). However, the current record is sufficiently developed for the court to grant a preliminary injunction on the basis that the State plan is not “in effect” statewide. Plaintiffs’ declarations establish that the current system for providing methadone maintenance creates a serious and immediate threat to the health and well-being of some recipients. See, e.g., Quilling Deck; Randall Deck; Randolph Deck Although the State has a legitimate interest in the continuity of its program, the administrative disruption required to provide interim relief to plaintiffs need not be any more substantial than that which occurred when the State intervened in Alameda County. See note 7, supra. While assuring that the State or all counties cover methadone maintenance services on a statewide basis will undoubtedly take some effort to implement, the plaintiffs are faced with serious and irreparable hardship, including serious health problems. On balance, the hardship suffered by plaintiffs outweighs the State’s interest in the continuity of its existing local option treatment system. Cf. Withrow v. Concannon, 942 F.2d 1385, 1387-88 (9th Cir.1991); Bracco v. Lackner, 462 F.Supp. 436, 452 (N.D.Cal.1978); Goldberg v. Kelly, 397 U.S. 254, 266, 90 S.Ct. 1011, 1019, 25 L.Ed.2d 287 (1970). Accordingly, plaintiffs are entitled to a preliminary injunction requiring that Medi-Cal funded methadone maintenance services must be made available to all residents of the State without regard to county of residence. B. Equal Access Under 42 U.S.C. § 1396a(a)(30), commonly called the “equal access” provision, a state Medi-Cal plan must provide such methods and procedures relating to the utilization of, and the payment for, care and services available under the plan ... as may be necessary to ... assure that payments are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area. 42 U.S.C. § 1396a(a)(30). The corresponding regulation provides that “the agency’s payments must be sufficient to enlist enough providers so that services under the plan are available to recipients at least to the extent that those services are available to the general population.” 42 C.F.R. § 447.204. 1. Jurisdiction. In its recent opinion in Arkansas Medical Soc’y, Inc. v. Reynolds, 6 F.3d 519 (8th Cir.1993), the Eighth Circuit held that the equal access provision may be enforced by Medicaid providers and recipients in a § 1983 action. After applying the relevant factors from Suter and Wilder, the court determined that the provision is “indisputably intended to benefit [ ] recipients” as well as providers. Id. at 526. Further, the statutory language, viewed in light of the entire legislative enactment and the legislative history, is expressed in mandatory rather than precatory terms. Id. Although some terms in the statute are ambiguous, applicable regulations and the legislative history supply sufficient guidance to the states concerning compliance, and also supply the judicially manageable standards needed to evaluate that compliance. Id. at 527. The court concluded that the equal access provision unambiguously confers a right within the meaning of Suter. Id. at 527-28. The analysis in Arkansas Medical Soc’y is persuasive, and thus the plaintiffs have a § 1988 cause of action to enforce § 1396a(a)(30). 2. Merits. Plaintiffs claim that the State is violating the equal access provision in two ways. First, defendants’ “method of paying” for methadone maintenance allows a county to eliminate the service from its array of drug treatment programs. As a result, the State’s payments are zero in the counties which choose to forego Medi-Cal funding even though private-pay methadone maintenance services are available in some of these counties. Second, the State’s “administration” of Medi-Cal methadone maintenance results in “gross disparities” between services available to private-pay patients and services available to the Medi-Cal eligible in counties which do opt to provide the service. Pis.’ Supp. in first Summ.J.Mot. at 28. This disparity results from funding constraints which translate to a limited number of MediCal treatment slots. Plaintiffs seek to give the equal access provision too broad a scope. The conduct of which they complain—the denial of all services in some counties and the limitation on slots in others—may violate other provisions of the Medicaid Act, but it is not prohibited by a provision that concerns only the rate of reimbursement. The statute and its corresponding regulation prohibit “payments” which result in disparities in service. It is evident from this language and the legislative history that the equal access provision is directed at prohibiting the payment of insufficient reimbursement rates to providers. In 1989, Congress codified the equal access statute, which previously had been contained only in a regulation. The House Report indicates that in this section Congress was concerned only with the rates paid for services supplied by existing providers: Under current law, states have discretion in establishing payment rates ... for physician services under their Medicaid programs .... A physician’s decision to accept Medicaid patients is affected by many factors ... [including] the payment rate itself____ As [stated in testimony before Congress], ‘There is no doubt that Medicaid reimbursement rates have not kept pace with average community rates.’ ... States have restrained physician fees [to control] program costs____ [T]he Committee believes that, without adequate payment levels, it is simply unrealistic to expect physicians to participate in the program ____ The Committee bill would codify ... the current regulation, 42 C.F.R. § 447.204, requiring adequate payment levels.... [T]he Medicaid payments would have to be at a level that ensures that Medicaid beneficiaries in that area have at least the same access to physicians as the rest of the insured population in that area. The Committee bill would not require that Medicaid payment levels be high enough to induce physicians to relocate into this area. H.R.Rep. 247, 101st Cong., 1st Sess. (1989), reprinted in 1989 U.S.C.C.A.N. 1906, 2060, 2115-16 (emphasis added). Plaintiffs do not cite, and the court has not found, any authority holding the equal access provision applicable to disputes challenging the distribution of services independently of the reimbursement rate paid. Cf. Arkansas Medical Soc’y, 6 F.3d at 519 (challenge to 20 percent across the board cut in reimbursement rates); Clark v. Kizer, 758 F.Supp. 572, 578 (E.D.Cal.1990) (noting that “the statute directs the State’s attention to reimbursement levels”; reimbursing dentists at 40 percent of their usual rates violates the equal access requirement), affd in part and vacated in part on other grounds sub nom., Clark v. Coye, 967 F.2d 585 (9th Cir.1992) (table); King v. Sullivan, 776 F.Supp. 645, 654-55 (D.R.I.1991) (equal access challenge rejected when the gist of plaintiffs’ complaint was a shortage of a particular type of Medicaid service). The equal access provision is directed at a particular problem—inadequate reimbursement rates—and the court declines to expand it to encompass plaintiffs’ claims regarding the inadequate amount and distribution of services available. The provision and distribution of services is specifically addressed in other sections of the Medicaid Act, including §§ 1396a(a)(1), 1396a(a)(8), and 1396a(a)(10)(B), and these sections must govern the resolution of plaintiffs’ claim. Because Medi-Cal reimbursement rates for methadone maintenance treatment compare favorably to the rates paid by private-pay patients, see Decl. of Allan F. Harlow, ¶7, plaintiffs have failed to raise serious questions going to the merits of their claim that the State has violated the equal access provision. Summary judgment is not appropriate for plaintiffs for the same reason. C. Comparability for Categorically Needy Individuals 42 U.S.C. § 1396a(a)(10)(B) creates an equality principle by which all categorically needy individuals must receive medical assistance which is no less than that provided to any other categorically or medically needy individual. 1. Jurisdiction. Section 1396a(a)(10)(B) creates a federal right that can be enforced under § 1983 by those plaintiffs who are categorically needy within the meaning of 42 U.S.C. § 1396a(a)(10)(A). First, the comparability 2’equirements contained in § 1396a(a)(10)(B) are intended to benefit the categorically needy plaintiffs in this case. The statute addresses the benefits to be received by “any [categorically needy] individual ” in relation to benefits received by other categorically needy individuals or by medically needy individuals. 42 U.S.C. § 1396a(a)(10)(B) (emphasis added). Similarly, the implementing regulation refers to “services available to any individual ” or “any categorically needy recipient.” 42 C.F.R. § 440.240 (emphasis added). Thus, the language of § 1396a(a)(10)(B) and 42 C.F.R. § 440.240 indicates that the Act’s comparability provision is designed to benefit individuals who are categorically needy, such as plaintiffs. Second, like the other sections of the Act at issue in this case, § 1396a(a)(10)(B) is phrased in mandatory, not precatory, terms. The statute provides that a state plan for medical assistance “must ... provide ... that the medical assistance made to any [categorically needy] individual ... shall not be less in amount, duration, or scope than the medical assistance made available” to any other categorically needy individual or to medically needy individuals. 42 U.S.C. § 1396a(a)(10)(B) (emphasis added). Third, the statute is sufficiently precise to be within the competence of the judiciary to enforce. Section 1396a(a)(10)(B) requires the states to provide all individuals who are categorically needy with medical assistance at least as extensive, in terms of “amount, duration, or scope,” as that provided to the medically needy or to any other categorically needy person. These directions provide courts with an objective “benchmark,” see Wilder, 496 U.S. at 519, 110 S.Ct. at 2523, against which to measure a state’s performance. Because the statutory and regulatory scheme “presents a straightforward, identifiable standard ... readily susceptible of judicial evaluation,” Albiston v. Maine Comm’r of Human Serv., 7 F.3d 258, 267 (1st Cir.1993), the court has jurisdiction over a claim brought under § 1983 to enforce § 1396a(a)(10)(B). 2. Merits. The plain language of § 1396a(a)(10)(B) requires that a state plan for medical assistance must provide that each categorically needy individual receive medical assistance not less in amount, duration, and scope than that received by other categorically needy persons or by medically needy persons in the state. It is undisputed that the Drug/Medi-Cal program fails to fund enough methadone maintenance slots for all of the categorically needy who are eligible for the service. By denying the same service to the categorically needy members of the plaintiff class that is received by other categorically needy persons and by some medically needy persons, the State violates § 1396a(a)(10)(B). Plaintiffs are entitled to summary judgment on this claim. Defendants make two principal arguments in an attempt to avoid this conclusion. First, they claim that § 1396a(a)(10)(B) is designed to ensure comparability between the various groups that comprise the categorically needy, not to ensure comparability within each such group. Second, defendants argue that even if the Medicaid Act requires comparability within the different groups of the categorically needy, comparability only extends to the “amount, duration, and scope” of medical assistanee, which is not implicated when providers are forced by State budgetary shortfalls to place some, but not all, categorically needy persons on waiting lists for Medi-Cal funded treatment slots. Neither of these arguments is persuasive. a. Comparability Within Groups of the Categorically Needy. Defendants claim that § 1396a(a)(10)(B) seeks to ensure comparable services for the distinct groups that make up the categorically needy, not parity for individuals within those distinct groups. Defendants cite Schweiker v. Hogan, 457 U.S. 569, 573 n. 6, 102 S.Ct. 2597, 2601 n. 6, 73 L.Ed.2d 227 (1982), which notes that the legislative history of the section refers to the need to “eliminate some of the unevenness which has been apparent in the treatment of the medical needs of various groups of the needy.” Id. (quoting H.R.Rep. No. 213, 89th Cong., 1st Sess. 66 (1965)) (emphasis added). Defendants also rely on the initial language of § 1396a(a)(10)(B), prior to its amendment in 1973, which seemingly required comparability between groups of the categorically needy. The present language of the statute, however, expressly requires that any categorically needy individual receive medical assistance not less in amount, duration, and scope than that received by “any other such individual.” 42 U.S.C. § 1396a(a)(10)(B)(i). Given “the basic and unexceptional rule that courts must give effect to the clear meaning of statutes as written,” Estate of Cowart v. Nicklos Drilling Co., — U.S.-,-, 112 S.Ct. 2589, 2594, 120 L.Ed.2d 379 (1992), defendants’ argument must be rejected. All relevant reported cases and scholarly authority examining § 1396a(a)(10)(B) support this conclusion. See, e.g., White v. Beal, 555 F.2d 1146, 1149 (3d Cir.1977) (“[A]ll persons within a given category must be treated equally.”); Becker v. Toia, 439 F.Supp. 324, 333 (S.D.N.Y.1977) (noting that under the comparability provisions of the Act, each categorically needy person “shall be eligible for the same ‘amount, duration and scope’ of coverage as all the others in his or her group”); Roe v. Casey, 464 F.Supp. 487, 494 (E.D.Pa.1978) (“[T]he medical assistance made available to either a categorically needy or medically needy person shall not be less in amount, duration or scope than the medical assistance made available to any other person in that particular category.”), aff'd, 623 F.2d 829 (3d Cir.1980); Schultz & Parmenter, Medical Necessity, AIDS, and the Law, 9 St. Louis U.Pub.L.Rev. 379 (1990) (“The equitable distribution requirement mandates that the medical assistance provided to any individual within a given group of ... categorically needy ‘shall not be less in amount, duration, or scope than the medical assistanee made available to any other such individual....”) (quoting 42 U.S.C. § 1396a(a)(10)(B)). Mississippi v. Sullivan, 951 F.2d 80 (5th Cir.1992), is not to the contrary. In Sullivan, the court interpreted 42 U.S.C. § 1396a(a)(17) to require comparability between and not within groups of the categorically needy with respect to the standards used to determine eligibility for medical assistance. However, § 1396a(a)(17) explicitly requires that standards be “comparable for all groups [of the categorically needy],” while § 1396a(a)(10)(B) refers to comparable treatment for categorically needy “individuals.” Congress’ use of different language in §§ 1396a(a)(10)(B) and 1396a(a)(17) suggests that Congress intended a different standard in the two sections, and provided for comparability between groups in § 1396a(a)(17) but within groups in § 1396a(a)(10)(B). See Russello v. United States, 464 U.S. 16, 23, 104 S.Ct. 296, 300, 78 L.Ed.2d 17 (1983) (“[W]here Congress includes particular language in one section of a statute but omits it in another section of the same Act, it is generally presumed that Congress acts intentionally and purposely in the disparate inclusion or exclusion.”) (quoting United States v. Wong Kim Bo, 472 F.2d 720, 722 (5th Cir.1972) (alteration in original)) b. Medical Assistance Less in Amount, Duration, or Scope. Defendants argue that placement of plaintiffs on waiting lists is not the same as providing them with medical assistance that is less in “amount, duration, or scope” than that received by others through Medi-Cal. They claim that waiting lists have nothing to do with amount, duration, or scope of medical assistance: Since all eligible recipients eventually will receive the same services and reimbursement for such services, § 1396a(a)(10)(B) is satisfied. The State’s argument brings to mind Lord Keynes’ rejoinder that “in the long run we are all dead.” In the long run all categorically needy persons may receive services. But in the meantime they do not, and life does not stop for them during this interim period. For anyone in immediate need of medical treatment, the value of medical services provided in the future is less than the value of medical services provided when needed, particularly when the need is great. See Greenstein v. Bane, 833 F.Supp. 1054, 1074 (S.D.N.Y.1993) (plaintiffs “forced to pay for treatment or services which are furnished to ordinary Medicaid recipients without charge ... have not received assistance equal in amount to the assistance received by these other recipients who pay nothing. As compared with other Medicaid recipients, plaintiffs’ medical assistance has diminished in value”); cf. Clark v. Kizer, 758 F.Supp. 572, 580 (E.D.Cal.1990) (granting summary judgment to plaintiffs, in part, on ground that varying availability of Denti-Cal (the dental component of California’s Medicaid program) violated the comparability requirement of the Medicaid Act), aff'd in part and vacated in part on other grounds sub nom., Clark v. Coye, 967 F.2d 585 (9th Cir.1992) (table); Hodecker v. Blum, 525 F.Supp. 867, 873 (N.D.N.Y.1981) (holding that State’s Medicaid budgetary process, which required the relatives of adult Medicaid recipients to contribute more than the relatives of minor Medicaid recipients to a patient’s care, violated the comparability rule for categorically needy persons), aff'd, 685 F.2d 424 (2d Cir. 1982). Thus, the delay of medical services to some of the categorically needy violates the “amount, duration, or scope” requirement of the comparability provision. A holding that the State violates § 1396a(a)(10)(B) by funding Medi-Cal in such a way as to create waiting lists is not inconsistent with other provisions in the Act and with cases such as Alexander v. Choate, 469 U.S. 287, 105 S.Ct. 712, 83 L.Ed.2d 661 (1985), which emphasize that states have substantial discretion to choose the proper amount, scope, and duration limitations on coverage. Despite the comparability requirement, the State retains substantial discretion in determining eligibility standards and in choosing the overall mix of optional benefits to include in its plan. Plaintiffs are entitled to summary judgment on their claim brought under § 1396a(a)(10)(B). D. Service Sujjvcient in Amount, Duration, and Scope Plaintiffs seek relief on their claim that the State, by denying methadone maintenance treatment to some who are Medi-Cal eligible, for reasons other than medical necessity, has violated the regulation found at 42 C.F.R. § 440.230(b): “Each service must be sufficient in amount, duration and scope to reasonably achieve its purpose.” Plaintiffs claim, and it appears from a review of the statutes listed in 42 C.F.R. § 440.200 as the source of the regulation, that § 440.230(b) implements § 1396a(a)(10)(B). Yet the regulation—directed to the sufficiency of each medical service to achieve the purpose of the service—has little relation to the comparability requirement contained in the statute. Whether a regulation, independent of an underlying statute, is enforceable under § 1983 is a matter of some uncertainty. Plaintiffs rely on Wright v. City of Roanoke Redevelopment and Housing Authority, 479 U.S. 418, 107 S.Ct. 766, 93 L.Ed.2d 781 (1987), for the proposition that “a federal regulation can create an enforceable right under section 1983.” Pis.’ Supp. in first Summ.J.Mot. at 22 n. 14. Indeed, some circuits have adopted such an interpretation of the holding in Wright. See West Virginia Univ. Hosp., Inc. v. Casey, 885 F.2d 11, 18 (3d Cir.1989) (“[V]alid federal regulations as well as federal statutes may create rights enforceable under section 1983.”), aff'd on other grounds, 499 U.S. 83, 111 S.Ct. 1138, 113 L.Ed.2d 68 (1991); Samuels v. District of Columbia, 770 F.2d 184, 199 (D.C.Cir.1985) (“[S]eetion 1983 provides a legal remedy for the violation of all valid federal laws, including at least those federal regulations adopted pursuant to a clear congressional mandate that have the full force and effect of law.”); see also Ermler v. Town of Brookhaven, 780 F.Supp. 120, 122 (E.D.N.Y.1992). But Wright is susceptible to a more limited interpretation. In holding that public housing tenants could enforce the Brooke Amendment to the Housing Act and its implementing regulations under § 1983, the majority opinion examined the statute and regulation together to determine whether they conferred specific, definable rights on plaintiffs. See Wright, 479 U.S. at 429-33, 107 S.Ct. at 773-76. The regulation at issue in Wright defined a term used in the statute itself; unlike the regulation here, it neither stood alone nor was analyzed independently of its statutory mooring. Id. at 420, 107 S.Ct. at 768-69. Only the dissent raised the question “whether administrative regulations alone could create [an enforceable] right.” Id. at 437, 107 S.Ct. at 777 (O’Connor, J., dissenting); see also id. (“This is a troubling issue not briefed by the parties, and I do not attempt to resolve it here.”). In the Ninth Circuit, whether a regulation standing alone may create enforceable rights is apparently an open question. See Howard v. City of Burlingame, 937 F.2d 1376, 1380 (9th Cir.1991) (noting that “federal regulations ... may define legal obligations enforceable under section 1983”; “[t]here is some question, however, whether they may create rights not already implied by the enabling statute”). Although plaintiffs cite several eases where courts have decided the merits of § 440.-230(b) claims standing alone, not one of these eases addresses the jurisdictional issue. See, e.g., Weaver v. Reagen, 886 F.2d 194, 198 (8th Cir.1989); White v. Beal, 555 F.2d 1146, 1151 (3d Cir.1977); King v. Sullivan, 776 F.Supp. 645, 653 (D.R.I.1991); Linton v. Carney, 779 F.Supp. 925, 936 (E.D.Tenn.1990); Ledet v. Fischer, 638 F.Supp. 1288, 1293 (M.D.La.1986); Allen v. Mansour, 681 F.Supp. 1232, 1237 (E.D.Mich.1986). Even assuming the “amount, duration and scope” regulation may be enforced independently of any statutory section that generally confers the same right, it is unclear that the regulation is framed with the requisite specificity to create an enforceable right under Suter. The regulation provides that each Medicaid service must be “sufficient ... to reasonably achieve its purpose.” What is considered reasonable, however, is not defined. The precise definition would seem to “vary with the circumstances of each individual case,” a characteristic which, under Suter, is not associated with an enforceable right under § 1983. Suter, — U.S. at-, 112 S.Ct. at 1368. Although Wilder and Suter look to guidance from statutory language, regulations, and legislative history to provide the necessary specificity, plaintiffs here offer only judicial interpretations to clarify the section. In King, the court provides one interpretation: When a state commits itself to providing Medicaid services, 42 C.F.R. § 440.230(b) simply obligates the state to provide them adequately, so that the state does not nominally recognize its obligations while failing to meet them financially. And the state need not meet its obligations perfectly. A service is sufficient in amount, duration and scope if it adequately meets the needs of most individuals eligible for Medicaid____ 776 F.Supp. at 652 (citing Charleston Memorial Hosp. v. Conrad, 693 F.2d 324, 330 (4th Cir.1982)). Accord Curtis v. Taylor, 625 F.2d 645, 653 (5th Cir.1980); see also Virginia Hosp. Ass’n v. Kenley, 427 F.Supp. 781, 786 (E.D.Va.1977) (construing an apparently earlier version of the regulation). In another line of cases, however, the courts have taken a different approach, holding a decision to deny services arbitrary and unreasonable under § 440.230(b) when it is made for reasons other than medical necessity. See Weaver, 886 F.2d at 198; White, 555 F.2d at 1151; Allen, 681 F.Supp. at 1237; Ledet, 638 F.Supp. at 1293. Other than these possibly inconsistent judicial interpretations, plaintiffs have directed the court to no other source for assistance in interpreting the origins or purpose of the vague language in the regulation. While more thorough briefing may shed additional light on this question, the court declines to determine whether the regulation creates enforceable rights in plaintiffs on the current state of the briefing. Further, even if the “amount, duration and scope” regulation is enforceable by private actions under § 1983, the scope of the states’ obligation under the regulation is unclear in light of the conflicting case law. E. Single State Agency A state’s Medicaid plan must “provide for the establishment or designation of a single State agency to administer or supervise the administration of the plan.” 42 U.S.C. § 1396a(a)(5). Implementing regulations provide, in pertinent part, that to qualify as a Medicaid agency (1) the agency must not delegate, to other than its own officials, authority to— (i) Exercise administrative discretion in the administration or supervision of the plan, or (ii) Issue policies, rules, and regulations on program matters. (3) If other State or local agencies or offices perform services for the Medicaid agency, they must not have the authority to change or disapprove any administrative decision of that agency, or otherwise substitute their judgment for that of the Medicaid agency with respect to the application of policies, rules, and regulations issued by the Medicaid agency. 42 C.F.R. § 431.10(e). Read with the regulation, the requirement of a single state agency is both mandatory in its terms and specific and detailed in its command to the states. Much more doubtful, however, is whether Medicaid recipients and providers are the intended beneficiaries of the single state agency requirement. The court concludes that they are not and thus that the section does not confer upon plaintiffs a right enforceable through § 1983. The single state agency clause is not phrased in terms of benefitting plaintiffs or providing services to plaintiffs. Compare Wilder, 496 U.S. at 510, 110 S.Ct. at 2517-18 (there can be “little doubt” that the Boren Amendment was intended to benefit health care providers since the language is “phrased in terms benefitting [them]” by requiring payment for health care services). Instead, it is phrased in terms of plan administration by a single agency. This focus is made more emphatic in the implementing regulation which forbids delegations of discretion or rule making authority to other agencies. Both the statute and regulation appear directed to the efficient and uniform operation of the Medicaid program, rather than to the provision of a direct or immediate benefit to Medicaid recipients or providers. Of course, any provision of the Medicaid Act may in some general sense be viewed as benefitting recipients, since this is the purpose of the statute as a whole. But such a generalized intent to benefit recipients is not enough under Wilder and Suter to confer a § 1983 cause of action. Here neither the statute nor the regulation unambiguously confers a benefit on recipients or providers. This view of the statutory language is supported by the legislative history of the section. The single state agency requirement first appeared in the original Social Security Act of 1935, and was copied, practically verbatim, into the Medicaid Act in 1965. See H.R. 4120, § 204, 74th Cong., 1st Sess. (1935), reprinted in Stevens, supra, at 100. The 1935 Act was enacted, in part, based on the recommendations and proposals of the President’s Committee on Economic Security, established by Executive Order in 1934. Stevens, supra, at 64. Documents submitted to the Committee reflect a debate regarding whether the social security program would be best administered solely by the federal government or instead under the system ultimately adopted—a system of federal-state cooperation, with each state administering its own program under federal requirements. See id. at 78; see also Guidice v. Jackson, 726 F.Supp. 632, 635 (E.D.Va.1989) (quoting Social Security Board, Social Security in America, A Summary of Staff Reports of the Committee on Economic Security 161, 191 (1937) (“The Committee recommended that responsibility for administration of the assistance be centralized within the state to ‘avoid a diversity o