Health Law Daily Wrap Up, GENERAL HEALTH CARE NEWS—6th Cir.: Nurse anesthetists’ association lacks standing to compel ACA enforcement, (Jul 22, 2026)

By Patricia K. Ruiz, J.D.

The court affirmed the dismissal of the suit, which sought to require HHS enforcement of the ACA’s nondiscrimination provision.

The court held that a national association of nurse anesthetists lacked Article III standing to pursue claims seeking to compel federal enforcement of the Affordable Care Act’s (ACA’s) provider nondiscrimination provision. The court concluded that the association failed to establish that its members’ alleged financial injuries were fairly traceable to the actions of HHS or that those injuries would likely be redressed by the requested relief. As a result, the court affirmed dismissal of the action challenging HHS’s alleged failure to enforce the statute against private health insurers (American Association of Nurse Anesthesiology v. Kennedy, No. 25-3733 (6th Cir. July 21, 2026)).

Background. The AANA, which represents nearly 74,000 nurse anesthetists, challenged reimbursement policies adopted by private insurers in 2023 and 2024 that reduced payments to nurse anesthetists practicing without medical direction to 85 percent of the rate paid to physician anesthesiologists. The association alleged that those policies violated the ACA’s nondiscrimination provision, which prohibits discrimination against healthcare providers acting within the scope of their licenses under state law.

The association asserted that the agency had failed to enforce the nondiscrimination provision or investigate alleged discrimination. It sought a writ of mandamus and relief under the Administrative Procedure Act (APA) compelling agency action allegedly unlawfully withheld or unreasonably delayed. The district court dismissed the case for lack of standing, and the association appealed.

Standing. The court explained that associational standing required the association to show that at least one member would have standing to sue individually. Even assuming the association had established an injury in fact through members’ alleged loss of reimbursement income, the court concluded that the causation and redressability requirements were not satisfied.

Causation. The court found that the alleged injuries stemmed from reimbursement decisions made by private insurers rather than by HHS. According to the court, the association’s theory that insurers were emboldened by the agency’s failure to enforce the ACA was too speculative to establish a predictable chain of causation. The court noted that HHS had never enforced the provision since its enactment in 2010, yet insurers did not alter their reimbursement practices until more than a decade later.

The court further observed that states possess primary enforcement authority under the ACA. Because federal enforcement becomes available only after a determination that a state has substantially failed to enforce the statute, the court concluded that the association’s theory did not adequately explain why HHS and the Secretary, rather than the states, caused the alleged injury.

Rejecting the association’s reliance on decisions recognizing standing based on predictable third-party reactions to government action, the court distinguished those cases as involving affirmative governmental regulation with coercive effects. The court declined to extend that reasoning to alleged governmental inaction.

Redressability. The court concluded that the requested relief would not likely redress the alleged injuries. It explained that a court order could only begin a process requiring the Secretary first to determine whether states had substantially failed to enforce the nondiscrimination provision. The Secretary might determine that states had not failed in that regard, eliminating any basis for federal enforcement action.

Even if the Secretary assumed enforcement authority, the court noted that agency regulations grant substantial discretion regarding investigations, enforcement priorities, and penalties. According to the court, it remained uncertain whether any enforcement action would be directed at the insurers identified by the association or whether any resulting penalties would alter insurer behavior.

The court further stated that insurers could respond to enforcement efforts in ways that would not remedy the alleged monetary injury, including reducing physician reimbursement rates instead of increasing payments to nurse anesthetists. Because several speculative events would have to occur before the requested relief could alleviate the alleged harm, the court found redressability lacking.

Concurring opinion. In a separate concurrence, Judge White agreed that the association lacked standing but concluded that the case should be analyzed through the framework of alleged agency abdication of enforcement responsibilities. The concurrence stated that the association had not shown complete abdication because the complaint involved a limited number of alleged violations over a relatively short period and because states hold primary enforcement responsibility under the statutory scheme. While questioning portions of the majority’s causation and redressability analysis, the concurrence agreed that the association failed to establish the type of complete abdication that might alter the standing analysis. The concurrence therefore agreed that dismissal was proper.

The case is No. 25-3733.

Judge: Thapar, A.

Attorneys: Mark J. Silberman (Benesch, Friedlander, Coplan & Aronoff LLP) for American Association of Nurse Anesthesiology. Lisa Hammond Johnson, U.S. Attorney’s Office, for Robert F. Kennedy, Jr. and U.S. Department of Health and Human Services.

Companies: American Association of Nurse Anesthesiology; U.S. Department of Health and Human Services

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