Two Planned Parenthood affiliates sued the state of Missouri today, seeking to prevent the Republican-led state from kicking them out of the Medicaid program because they offer abortions.

The bigger question is why the lawsuit was necessary under a Democratic president.

Federal law protects the right of Medicaid patients to go to any qualified provider for health care. The fact that a health center offers abortions is not a legitimate reason to ban Medicaid patients from going there for services like STI treatments, cancer screenings, and contraception—at least according to the Obama administration, which sent a letter to all 50 states in 2016 warning them against “defunding” Planned Parenthood under Medicaid. At least 10 states had moved to revoke Planned Parenthood’s Medicaid funding after anti-abortion activists released deceptively edited videos attacking the group in 2015. A number of these efforts resulted in lengthy court battles. Texas and Mississippi succeeded in stripping Planned Parenthood of Medicaid funding last year, following Arkansas in 2017. Court battles have blocked similar efforts in Louisiana and South Carolina.

Now, Planned Parenthood says Missouri is poised to be the fourth state to strip Medicaid reimbursements from the organization. And while the Biden administration has said it agrees with its Democratic predecessor’s interpretation of the law, it has yet to enforce it.

“For more than a year, we’ve warned the Biden administration: Missourians are in danger of losing access to their health care,” Yamelsie Rodríguez, president and CEO of Planned Parenthood of the St. Louis Region and Southwest Missouri said in a statement provided exclusively to The Nation ahead of the lawsuit.

“Now, we are pleading with them: Enforce Medicaid law immediately. Missouri is the fourth state to violate federal law, and without enforcement, it won’t be the last,” Rodríguez said.

The two affiliates said they will foot the bill so that Medicaid patients can still be seen at their health centers in Missouri. The second affiliate involved in the lawsuit is Planned Parenthood Great Plains (PPGP), which covers Missouri, Arkansas, Oklahoma, and Kansas and has spent the past six months absorbing patients flocking to its health centers from Texas, where a law that bans most abortions after six weeks has been in effect since September 1.

“We know what a crisis in care looks like, and conservative politicians are determined to force Missourians to endure the same horrors,” Emily Wales, interim president and CEO of PPGP, said in the statement. “The Medicaid law is clear, and Missouri is in desperate need of providers committed to seeing everyone who needs them.”

Protests erupted at the Missouri state house Wednesday over efforts by state lawmakers to defund Planned Parenthood beyond the current budget bill and copy the six-week, citizen-enforced abortion ban now in effect in Texas. Abortion rights supporters holding signs that read “Fuck abortion bans” packed the hallway outside a hearing room and waited to testify for over four hours until Republicans finally announced they were canceling the hearing.

Missouri made headlines earlier this week after a state lawmaker introduced a measure to allow private citizens to sue anyone who helps a Missouri resident obtain an abortion outside of the state. It’s an ominous sign of how Republican-controlled states might try to go beyond banning abortion within their borders. And as a wider emergency over abortion access looms, some advocates are disappointed with Biden’s lukewarm response to the crisis, even as national organizations have at times seemed hesitant to hold his feet to the fire. If the Supreme Court ends Roe v. Wade by June, as many expect, it will be on the watch of a Democratic president. Biden can’t protect Roe without Congress—which just last month failed to pass the bill that would have enshrined legal abortion into federal law. But enforcing the law to keep Medicaid payments flowing to health centers that happen to offer abortions would not require Congress. Nor would saying the word “abortion” out loud, which Biden has yet to do, according to reproductive justice activist Renee Bracey Sherman, who has been carefully keeping track.

Last November, a dozen Texas state senators wrote to the Biden administration, urging officials to enforce the federal Medicaid law. “President Biden, your administration has already warned that states cannot withhold Medicaid funding from Planned Parenthood and block people with Medicaid from accessing care at Planned Parenthood health centers,” the lawmakers wrote. “Now, we are asking you to act.”

Texas won a nearly five-year court battle to exclude Planned Parenthood affiliates from the state Medicaid program last year, blocking care to 8,000 low-income patients who relied on the health care provider. In January, Texas Attorney General Ken Paxton sued Planned Parenthood to recoup $10 million in Medicaid reimbursements that were already paid.

Missouri lawmakers have also been trying to revoke Medicaid funding from centers that offer abortions for years.

“It has become increasingly clear that lawmakers opposed to reproductive health care in Missouri are tempting the boundaries of Medicaid law,” Missouri Representative Cori Bush wrote in a letter to the Biden administration last November. “I urge the administration to denounce all actions that prevent Medicaid patients from accessing care at Planned Parenthood and any other abortion-providing health centers.”

Bush noted in her letter that even the Obama administration’s April 2016 guidance warning states over the targeting of Planned Parenthood came only after “the attacks that prompted the need for guidance had happened for months.”

In 2018, the Trump administration revoked the guidance. “This is part of the Trump administration’s effort to roll back regulations the Obama administration put out to radically favor abortion,” Charmaine Yoest, the former head of Americans United for Life who served as assistant secretary for public affairs at HHS under Trump, said at the time. The move seemed to have come at the behest of the right-wing group Alliance Defending Freedom, Vox reported.

In 2020, Missouri’s Supreme Court ruled that a prior effort by the state to defund Planned Parenthood through the budget was unconstitutional. But that didn’t stop Missouri Governor Mike Parson from signing a supplemental budget bill last month that would end Medicaid reimbursements to any organization that provides abortions—with the exception of hospitals—at least through June, when the bill expires. In a letter dated March 4, the Missouri Department of Social Services informed Planned Parenthood affiliates in the state that Medicaid claims submitted after Friday, March 11 would be suspended under the bill. Missouri is already one of more than 30 states that ban most Medicaid funding of abortion, so the bill applies only to non-abortion services like birth control, STI testing and treatment, and cancer screenings.

In a statement to The Nation, Planned Parenthood’s national office said it has “requested” that CMS enforce the federal requirement that protects the ability of patients to choose their provider, calling it “a vital step the Biden administration can take.” Planned Parenthood has launched a petition to pressure the Biden administration to act.

The Centers for Medicare and Medicaid Services has not yet responded to questions about whether it plans to take action in response to the requests.

So far, the Biden administration has heeded calls from reproductive health advocates on other issues, permanently lifting in-person dispensing rules for medication abortion; repealing a Trump-era executive order that forced organizations including Planned Parenthood to forego Title X family planning funding; and suing Texas over its six-week abortion ban. Biden’s inaugural budget excluded the ban on federal funding of abortion for the first time in decades, a major sign of progress after Biden himself had supported the Hyde Amendment for years—although the ban has been reinstated in Congress. Last month, abortion rights groups praised Biden’s nomination of Judge Ketanji Brown Jackson to be the first Black woman on the Supreme Court.

But there is more Biden could do in the face of congressional inaction. He could challenge laws in 19 states that require in-person dispensing of medication abortion in defiance of FDA guidelines and even lease federal land to abortion providers, as legal experts have suggested. He could also follow the lead of California, where Governor Gavin Newsom has proposed funding scholarships and loan repayments for abortion providers and vowed to make the state a “sanctuary” for people seeking abortions, in anticipation of the Supreme Court’s decision.

On March 1, reproductive justice activists including Bracey Sherman were hoping Biden would send them a symbolic victory by saying the word “abortion” during his State of the Union address. This seemed like the moment, with Roe in the crosshairs.

Instead, Biden declared that “the constitutional right affirmed in Roe v. Wade” is “under attack as never before,” without using the word “abortion.”

“If we want to go forward—not backward—we must protect access to health care,” Biden added. “Preserve a woman’s right to choose.”

Leading abortion rights organizations lauded Biden’s speech.

“We’re grateful that President Biden noted this pivotal moment for our movement during his address,” NARAL said in a statement.

“Thank you, POTUS for speaking about the national abortion access crisis at the #StateOfTheUnion,” Planned Parenthood Action tweeted.

But Bracey Sherman was disappointed. “Could you imagine if he talked about the attacks on the right to vote but never used the word ‘vote’?” she said. “That would be weird.”

Weirder still is the fact that Planned Parenthood affiliates have to fight for their patients’ Medicaid coverage in state court when there’s a pro-choice president in the White House.