Supreme Court rules in favor of HHS in Medicare disproportionate share hospital payment formula case; ruling affects how hospitals calculate low-income patient percentages for Medicare reimbursement

The Supreme Court today ruled(Slip Opinion) OCTOBER TERM, 2024 1 Syllabus NOTE: Where it is feasible, a syllabus (headnote) will be released, as is being done in connection with this case, at the time the opinion is issued. The syllabus constitutes no part of the opinion of the Court but has been prepared by the Reporter of Decisions for the convenience of the reader. See United States v. Detroit Timber & Lumber Co., 200 U. S. 321, 337. SUPREME COURT OF THE UNITED STATES Syllabus ADVOCATE CHRIST MEDICAL CENTER ET AL. v. KENNEDY, SECRETARY OF HEALTH AND HUMAN SERVICES CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE DISTRICT OF COLUMBIA CIRCUIT No. 23–715. Argued November 5, 2024—Decided April 29, 2025 When hospitals provide inpatient services to Medicare beneficiaries, the Medicare program pays those hospitals a fixed rate for treating each Medicare patient. See 42 U. S. C. §§1395ww(d)(1)–(4). Congress also provides various hospital-specific rate adjustments, including the “dis- proportionate share hospital” (DSH) adjustment, which offers addi- tional funding to hospitals that treat a high percentage of low-income patients. To calculate the DSH adjustment, the Department of Health and Human Services (HHS) adds together two statutorily prescribed fractions referred to as the Medicare fraction and the Medicaid frac- tion. §1395ww(d)(5)(F)(vi). The Medicare fraction “represents the pro- portion of a hospital’s Medicare patients who have low incomes,” and the Medicaid fraction “represents the proportion of a hospital’s pa- tients who are not entitled to Medicare and have low incomes.” Becerra v. Empire Health Foundation, for Valley Hospital Medical Center, 597 U. S. 424, 429–430. When the Medicare fraction is expressed as a per- centage and added to the Medicaid fraction’s percentage, the sum yields the disproportionate patient percentage. §1395ww(d)(5)(F)(vi). That percentage, in turn, determines whether a hospital will receive a DSH adjustment—and if so, how much. Relevant here, the numerator of the Medicare is defined by the stat- ute as “the number of [a] hospital’s patient days” attributable to pa- tients “who (for such days) were entitled to benefits under [Medicare] part A” and “entitled to supplementary security income [SSI] benefits 2 ADVOCATE CHRIST MEDICAL CENTER v. KENNEDY Syllabus . . . under subchapter XVI.” §1395ww(d)(5)(F)(vi)(I). This Court in Em- pire Health has held that the phrase “ ‘entitled to [Medicare Part A] benefits’ ” in the Medicare fraction includes “all those qualifying for the program, regardless of whether they are receiving Medicare payments for part or all of a hospital stay.” 597 U. S., at 445 (quoting §1395ww(d)(5)(F)(vi)(I); alteration in original). But the Court has not addressed the issue presented in this case—i.e., which patients count as being “entitled to [SSI] benefits . . . under subchapter XVI.” HHS interprets the language to mean patients who are entitled to receive an SSI payment during the month in which they were hospitalized. Petitioners—a group of more than 200 hospitals—insist that the phrase includes all patients enrolled in the SSI system at the time of their hospitalization, even if they were not entitled to an SSI payment during their month of hospitalization. The hospitals claim that, as a result of HHS’s misinterpretation of the phrase, HHS miscalculated the hospitals’ DSH adjustment and underfunded the hospitals from 2006 to 2009. The hospitals have lost at every stage of this litigation, including most recently before the D. C. Circuit. The D. C. Circuit con- cluded that SSI benefits in “subchapter XVI [are] about cash payments for needy individuals,” and that “it makes little sense to say that indi- viduals are ‘entitled’ to the benefit in months when they are not even eligible for [a payment].” Advocate Christ Medical Center v. Becerra, 80 F. 4th 346, 352–353. The Court granted certiorari. Held: In calculating the Medicare fraction, an individual is “entitled to [SSI] benefits” for purposes of the Medicare fraction when she is eligi- ble to receive an SSI cash payment during the month of her hospitali- zation. Pp. 6–16. (a) SSI benefits are cash benefits. See 42 U. S. C. ch. 7, subch. XVI. Section 1381a, which describes the basic entitlement to benefits, pro- vides that “[e]very . . . individual who is determined . . . to be eligible on the basis of his income and resources shall . . . be paid benefits.” (Emphasis added.) The word “paid” connotes cash. Section 1382(b)(1), which specifies the amount that the Social Security Administration must pay to eligible individuals, states that the benefits “shall be pay- able at the rate of [specific dollar amounts].” A benefit quantified in dollar amounts is plainly a cash benefit. Similarly, subchapter XVI’s codified statement of purpose is “to provide supplemental security in- come to individuals.” §1381 (emphasis added). Just as subchapter XVI makes clear that SSI benefits are cash ben- efits, it also establishes that eligibility for such benefits is determined on a monthly basis. Section 1382(c)(1) provides that “[a]n individual’s eligibility for a benefit under this subchapter for a month shall be de- termined” based on the individual’s “income, resources, and other rel- Cite as: 605 U. S. ____ (2025) 3 Syllabus evant characteristics in such month.” The statute’s reference to ter- mination of benefits also refers back to months of ineligibility, stating that an individual must reapply for the program after she has been “ineligible for benefits . . . for a period of 12 consecutive months.” §1383(j)(1)(B). Finally, although subchapter XVI speaks primarily in terms of eli- gibility for SSI benefits, the Medicare fraction focuses on whether an individual is entitled to such benefits. Nothing turns on this differ- ence. In Empire Health, the Court treated the word “entitled” in the Medicare statute as synonymous with “qualifying” for or “being eligi- ble . . . for benefits.” 597 U. S., at 435. This case also involves the Medicare fraction, so the Court follows the same course. Because eli- gibility for an SSI payment is determined on a monthly basis, an indi- vidual is considered “entitled to [SSI] benefits” for purposes of the Medicare fraction when she is eligible for such benefits during the month of her hospitalization. Pp. 6–9. (b) The hospitals’ broader reading of “entitled to [SSI] benefits” fails. Pp. 9–16. (1) While the hospitals characterize SSI benefits as including non- cash benefits—e.g., vocational rehabilitation services and continued Medicaid coverage—these noncash benefits do not fit the description of a “supplementa[l] security income” benefit. §1395ww(d)(5)(F)(vi)(I) (emphasis added). Further, none of the noncash benefits identified by the hospitals is housed “under subchapter XVI.” Ibid. (emphasis added). The hospitals’ reliance on the Ticket to Work and Self-Suffi- ciency Program falls short for this reason. Nor do any of subchapter XVI’s other references to vocational rehabilitation services confer an SSI benefit. Rather, §1382d’s references to certain services point to benefits housed elsewhere, but not within subchapter XVI. The hospitals’ reliance on continued Medicaid coverage pursuant to §1382h(b) also falls flat. In most States, eligibility for SSI benefits qualifies an individual for Medicaid coverage. While losing SSI bene- fits generally means losing Medicaid coverage, §1382h(b) allows cer- tain people ineligible for SSI benefits in a given month to be treated as if they remain eligible for SSI benefits so that they can continue re- ceiving Medicaid. But §1382h(b), which by its terms applies only to Medicaid (i.e., “subchapter XIX”), simply aids in the administration of the Medicaid program. It does not create an SSI benefit. Pp. 9–11. (2) The hospitals advance a second argument that eligibility for SSI benefits—even for purely cash benefits—begins when a person en- ters the SSI system and continues until the individual is ineligible for an SSI payment for 12 consecutive months. While it is true that a person first applying for benefits must disclose her income “rate” “for the calendar year,” §1382(a)(1)(A), that “calendar year” income does 4 ADVOCATE CHRIST MEDICAL CENTER v. KENNEDY Syllabus not render her eligible for SSI benefits, nor does it establish that SSI benefits operate in intervals with a duration longer than one month. Instead, the statute clearly directs eligibility decisions to be made monthly based on “the individual’s . . . income, resources, and other relevant characteristics in such month.” §1382(c) (emphasis added). Nor does the reapplication requirement change the nature of eligibil- ity. Under §1383(j)(1)(B), a once-eligible individual must submit a new application after she has been “ineligible for benefits . . . for a period of 12 consecutive months.” That provision does not state that a person remains eligible during this period; it states that a person who “was an eligible individual” at one point must reapply after 12 consecutive months of ineligibility. §1383(j)(1)(A) (emphasis added). The hospitals also assert that Empire Health supports their theory that being “entitled to [SSI] benefits” means that a patient is entitled to SSI benefits even if she does not qualify for a payment during the month of hospitalization. Not so. Just as Empire Health turned on the specific features of Medicare Part A, this case turns on the specific features of SSI benefits under subchapter XVI. Unlike Medicare Part A, which provides automatic, ongoing health insurance that “never goes away” absent diminished disability, Empire Health, 597 U. S., at 437, SSI benefits require recipients to apply for and be deemed eligible for benefits, and recipients can (and do) fluctuate in and out of eligibil- ity based on monthly income and resources. Consistency with Empire Health’s benefit-focused analysis thus requires the Court to recognize and give effect to the differences between Medicare Part A and SSI benefits. Pp. 11–14. (3) Finally, invoking statutory purpose, the hospitals argue that their broad reading of “entitled to [SSI] benefits” better advances Con- gress’s goal of providing additional funds to hospitals that serve a dis- proportionately high percentage of needy Medicare patients. But “[n]o statute pursues a single policy at all costs,” Bartenwerfer v. Buckley, 598 U. S. 69, 81, and the Court must respect the specific formula that Congress prescribed. Pp. 14–16. 80 F. 4th 346, affirmed. BARRETT, J., delivered the opinion of the Court, in which ROBERTS, C. J., and THOMAS, ALITO, KAGAN, GORSUCH, and KAVANAUGH, JJ., joined. JACKSON, J., filed a dissenting opinion, in which SOTOMAYOR, J., joined. Cite as: 605 U. S. ____ (2025) 1 Opinion of the Court NOTICE: This opinion is subject to formal revision before publication in the United States Reports. Readers are requested to notify the Reporter of Decisions, Supreme Court of the United States, Washington, D. C. 20543, pio@supremecourt.gov, of any typographical or other formal errors. SUPREME COURT OF THE UNITED STATES _________________ No. 23–715 _________________ ADVOCATE CHRIST MEDICAL CENTER, ET AL., PETITIONERS v. ROBERT F. KENNEDY, JR., SECRETARY OF HEALTH AND HUMAN SERVICES ON WRIT OF CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE DISTRICT OF COLUMBIA CIRCUIT [April 29, 2025] JUSTICE BARRETT delivered the opinion of the Court. The Medicare program, which provides health insurance to elderly or disabled Americans, is governed by a notori- ously complex statute. Unsurprisingly, then, the provision at issue in this case is highly technical: It prescribes a per- centage used to calculate the rate that the Government will pay a hospital that treats a disproportionate share of low- income Medicare patients. The percentage is determined by the sum of two fractions—the so-called Medicare fraction and Medicaid fraction. Relevant here, the numerator of the Medicare fraction counts the number of patient days at- tributable to Medicare patients who were “entitled to bene- fits under [Medicare] part A” and were “entitled to supple- mentary security income benefits . . . under subchapter XVI.” 42 U. S. C. §1395ww(d)(5)(F)(vi)(I). In Becerra v. Empire Health Foundation, for Valley Hos- pital Medical Center, we held that the phrase “ ‘entitled to [Medicare Part A] benefits’ ” includes “all those qualifying for the program, regardless of whether they are receiving Medicare payments for part or all of a hospital stay.” 597 2 ADVOCATE CHRIST MEDICAL CENTER v. KENNEDY Opinion of the Court U. S. 424, 445 (2022) (quoting §1395ww(d)(5)(F)(vi)(I); al- teration in original). We did not decide, however, what it means to be “entitled to supplementary security income benefits . . . under subchapter XVI.” §1395ww(d)(5)(F) (vi)(I). Today, we hold that a person is entitled to such ben- efits when she is eligible to receive a cash payment during the month of her hospitalization. I The Medicare program reimburses hospitals that provide inpatient services to Medicare beneficiaries. See §1395ww(d). As a rule, the “program pays a hospital a fixed rate for treating each Medicare patient, based on the pa- tient’s diagnosis,” which is “designed to reflect the amounts an efficiently run hospital, in the same region, would ex- pend to treat a patient with the same diagnosis.” Id., at 429 (citing §§1395ww(d)(1)–(4) and 42 CFR §412.2 (2022)). Be- cause the fixed-rate payment is provided “regardless of the hospital’s actual costs,” it “gives hospitals an incentive to provide efficient levels of medical service.” Empire Health, 597 U. S., at 429. Congress also “provided for various hospital-specific rate adjustments—including the one at issue here for treating low-income patients.” Ibid. That adjustment is called the “disproportionate share hospital” (DSH) adjustment, which provides “hospitals serving an ‘unusually high percentage of low-income patients’ enhanced Medicare payments.” Ibid. (quoting Sebelius v. Auburn Regional Medical Center, 568 U. S. 145, 150 (2013)). This adjustment accounts for the fact that “low-income individuals are often more expen- sive to treat than higher income ones, even for the same medical conditions.” Empire Health, 597 U. S., at 429. The enhanced payment incentivizes hospitals to treat low- income patients. See ibid. In Empire Health, we described the DSH adjustment in Cite as: 605 U. S. ____ (2025) 3 Opinion of the Court great detail, so here, we will be brief. To calculate a hospi- tal’s DSH adjustment, the Department of Health and Hu- man Services (HHS) adds together “two statutorily de- scribed fractions, usually called the Medicare fraction and the Medicaid fraction.” Ibid.; see §1395ww(d)(5)(F)(vi). To- gether, these fractions are “designed to capture two differ- ent low-income populations that a hospital serves.” Id., at 429. The “Medicare fraction represents the proportion of a hospital’s Medicare patients who have low incomes, as iden- tified by their entitlement to supplementary security in- come (SSI) benefits.” Id., at 429–430. And “[t]he Medicaid fraction represents the proportion of a hospital’s patients who are not entitled to Medicare and have low incomes, as identified by their eligibility for Medicaid.” Id., at 430. Like Empire Health, this case concerns the Medicare frac- tion, which is defined as: “the fraction (expressed as a percentage), the nu- merator of which is the number of such hospital’s patient days for such period which were made up of patients who (for such days) were entitled to ben- efits under part A of this subchapter and were en- titled to supplementary security income benefits (excluding any State supplementation) under sub- chapter XVI of this chapter, and the denominator of which is the number of such hospital’s patient days for such fiscal year which were made up of pa- tients who (for such days) were entitled to benefits under part A of this subchapter.” §1395ww(d) (5)(F)(vi)(I).1 In plainer English, the Medicare fraction works like this: —————— 1 Although the Medicare fraction employs the phrase “supplementary security income,” §1395ww(d)(5)(F)(vi)(I) (emphasis added), subchapter XVI refers to this benefit as “supplemental security income,” §1381 (em- phasis added). Despite the slight variation in wording, these two phrases refer to the same benefit. 4 ADVOCATE CHRIST MEDICAL CENTER v. KENNEDY Opinion of the Court The numerator counts “the number of patient days attribut- able to Medicare patients who are poor”—i.e., those Medi- care patients who are entitled to SSI benefits under sub- chapter XVI. Id., at 430. The denominator counts “the number of patient days attributable to all Medicare pa- tients.” Ibid. When the Medicare fraction is expressed as a percentage and added to the Medicaid fraction’s percent- age, the sum of the two yields the “ ‘disproportionate patient percentage.’ ” §1395ww(d)(5)(F)(vi). The resulting percent- age “determines whether a hospital will receive a DSH ad- justment”—and if so, how much. Id., at 431. “The higher the disproportionate-patient percentage,” the more funding a hospital receives. Id., at 432 (citing §§1395ww(d)(5) (F)(vii)–(xiv)). For purposes of this case, the key phrase in the Medicare fraction is “entitled to supplementary security income ben- efits . . . under subchapter XVI.” §1395ww(d)(5)(F)(vi)(I). Supplemental security income is “a subsistence allowance” offered to the country’s “needy aged, blind, and disabled.” Schweiker v. Wilson, 450 U. S. 221, 223 (1981); see also §1381 (describing subchapter XVI as a “national program to provide supplemental security income to individuals who have attained age 65 or are blind or disabled”). HHS inter- prets the relevant text to refer to patients who are “entitled to receive SSI benefits during the month” in which they were hospitalized. 75 Fed. Reg. 50281 (2010).2 —————— 2 To calculate the number of people eligible for SSI benefits in a par- ticular month, HHS obtains data from the Social Security Administra- tion (SSA) that seeks to “captur[e] all SSI-entitled individuals during the month(s) that they are entitled to receive SSI benefits.” 75 Fed. Reg. 50281. SSA collects this data by identifying certain “status codes” that indicate whether a person was entitled to SSI benefits during a particu- lar month. Ibid. As part of a 2010 rulemaking, HHS evaluated various codes used by SSA and concluded that three codes (C01, M01, and M02) capture the relevant population of those entitled to a monthly SSI cash benefit. Ibid. Code C01 represents SSI enrollees who receive an auto- matic cash payment, and codes M01 and M02 represent SSI enrollees Cite as: 605 U. S. ____ (2025) 5 Opinion of the Court Petitioners, a group of more than 200 hospitals, disagree with this interpretation. They insist that the phrase en- compasses all patients enrolled in the SSI system at the time of their hospitalizations, even if those patients were not entitled to an SSI payment during that month. This approach sweeps more people into the numerator of the Medicare fraction, thereby increasing the amount of fund- ing a hospital may receive. See §§1395ww(d)(5)(F)(vii)– (xiv). The hospitals claim that because HHS misconstrued the Medicare fraction, it underfunded them during the fis- cal years 2006 to 2009. The hospitals have lost at every step of this litigation. The Provider Reimbursement Review Board, a tribunal within HHS, denied the hospitals’ request for additional re- imbursement on procedural grounds. The Centers for Med- icare & Medicaid Services, which administers Medicare for HHS, also denied relief, this time on the merits. The hos- pitals then sought review in the District Court, which re- jected their claims and granted summary judgment to HHS. —————— whose cash payments are managed manually. See Advocate Christ Med- ical Center v. Becerra, 80 F. 4th 346, 350, n. 1 (CADC 2023). As part of that rulemaking, HHS rejected a proposal to begin using additional SSA codes that, according to the commenter, “represent individuals who [are] eligible for SSI, but not eligible for SSI payments” in a given month, in- cluding because the individual is in “suspended” status. 75 Fed. Reg. 50280–50281; see 20 CFR §§416.1320–416.1330, 416.1339 (2024) (de- scribing suspension of benefits payments). In rejecting this proposal, HHS explained that “none of the SSI status codes . . . mentioned would be used to describe an individual who was entitled to receive SSI benefits during the month that one of those status codes was used.” 75 Fed Reg. 50281. This case does not present the question whether HHS correctly in- cludes only three SSI status codes as part of its calculation for the Med- icare fraction. Below, the D. C. Circuit declined to consider whether HHS “unreasonably excluded from the Medicare fraction individuals as- signed codes ‘S’ and ‘E02’ ” because the hospitals raised the argument for the first time in their reply brief. 80 F. 4th, at 354. We too decline to consider this issue. 6 ADVOCATE CHRIST MEDICAL CENTER v. KENNEDY Opinion of the Court See Advocate Christ Medical Center v. Azar, No. 17–cv– 1519 (D DC, June 8, 2022), App. to Pet. for Cert. 18. The D. C. Circuit also agreed with HHS. See Advocate Christ Medical Center v. Becerra, 80 F. 4th 346 (2023). In explain- ing that SSI benefits in “subchapter XVI [are] about cash payments for needy individuals,” the D. C. Circuit observed that “it makes little sense to say that individuals are ‘enti- tled’ to the benefit in months when they are not even eligi- ble for [a payment].” Id., at 352–353. We granted certio- rari. 601 U. S. ___ (2024). II To determine when a person is “entitled to supplemen- tary security income benefits,” §1395ww(d)(5)(F)(vi)(I), we must know what the benefits are. See Empire Health, 597 U. S., at 435–439. The answer is clear: SSI benefits are cash benefits. See 42 U. S. C. ch. 7, subch. XVI. Section 1381a, which describes the basic entitlement to benefits, provides that “[e]very . . . individual who is determined . . . to be eligible on the basis of his income and resources shall . . . be paid benefits by the Commissioner.” (Emphasis added.) The word “paid” obviously connotes a cash benefit. Section 1382(b) sings the same tune: It specifies the amount that SSA is required to pay eligible individuals, stating that “[t]he benefit under this subchapter . . . shall be payable at the rate of [specific dollar amounts].” §1382(b)(1). A benefit quantified in dollar amounts is plainly a cash benefit. Ech- oing the point, other provisions explain how and when the cash benefit is to be paid to recipients. See, e.g., §1383 (pre- scribing procedures for the “payment of benefits” (boldface deleted)); §1383(a)(4)(A) (permitting a “cash advance against such benefits” to individuals in limited circum- stances).3 Subchapter XVI’s codified statement of purpose —————— 3 See also §1382(h) (describing rules for “determining eligibility for, and the amount of, benefits payable” to individuals who receive other types of financial assistance); §1382f(a) (providing an “[i]ncrease of dollar Cite as: 605 U. S. ____ (2025) 7 Opinion of the Court is of a piece: to “establis[h] a national program to provide supplemental security income to individuals who have at- tained age 65 or are blind or disabled.” §1381 (emphasis added). “Income” is “a gain or recurrent benefit that is usu[ally] measured in money and for a given period of time.” 2 Webster’s Third New International Dictionary 1143 (1971). Statutory provisions outside subchapter XVI also under- stand the phrase “[SSI] benefits . . . under subchapter XVI” to mean a cash benefit. Take §1320b–19 in subchapter XI, which directs the Commissioner of Social Security to estab- lish the Ticket to Work and Self-Sufficiency Program. Sec- tion 1320b–19 defines the phrase “supplemental security income benefit” to mean “a cash benefit under section 1382 or 1382h(a) of this title.” §1320b–19(k)(5); see also §1320a– 6(b) (defining the term “supplemental security income ben- efits” to “mea[n] benefits paid or payable by the Commis- sioner of Social Security under subchapter XVI”). Same too in subchapter VIII, which provides special benefits for cer- tain World War II veterans. There, Congress defined the “ ‘[f]ederal benefit rate under subchapter XVI’ ” to mean “with respect to any month, the amount of the supple- mental security income cash benefit.” §1012(4). Just as subchapter XVI makes clear that SSI benefits are cash benefits, it also establishes that eligibility for such benefits is determined on a monthly basis. Section 1382(c)(1) provides that “[a]n individual’s eligibility for a benefit under this subchapter for a month shall be deter- mined” based on the individual’s “income, resources, and other relevant characteristics in such month.” The statute’s reference to termination of benefits also refers back to months of ineligibility: An individual must reapply for the —————— amounts” of SSI benefits based on cost-of-living adjustments (boldface deleted)); §1383(b)(1)(A) (providing “appropriate adjustments in future payments” in the case of overpayments or underpayments of SSI bene- fits). 8 ADVOCATE CHRIST MEDICAL CENTER v. KENNEDY Opinion of the Court program after she has been “ineligible for benefits . . . for a period of 12 consecutive months.” §1383(j)(1)(B). Other ex- amples similarly confirm that eligibility is a month-to- month inquiry. See, e.g., §1382(e)(1)(A) (providing that “no person shall be an eligible individual . . . with respect to any month if throughout such month he is an inmate of a public institution”); §1382(e)(1)(D) (providing that “[a] person may be an eligible individual . . . with respect to any month throughout which he is a resident of a public emergency shelter for the homeless”); §§1382(e)(4)(A)(i)–(ii) (providing that “[n]o person shall be considered an eligible individual . . . with respect to any month if during such month the per- son is . . . fleeing to avoid prosecution” or violating “a condi- tion of probation or parole”). A note for the sake of completeness: While subchapter XVI speaks primarily in terms of eligibility for SSI benefits, the Medicare fraction focuses on whether an individual is entitled to such benefits. Nothing turns on this difference. In Empire Health, we treated the word “entitled” in the Medicare statute (including the Medicare fraction) as syn- onymous with “qualifying” for or “being eligible . . . for ben- efits.” 597 U. S., at 435. See also Webster’s Third New In- ternational Dictionary 758 (1986) (defining “entitle” as “to give a right or legal title to” or to “qualify (one) for some- thing”); id., at 736 (defining “eligible” as “fitted or qualified to be chosen or used” or “entitled to something”). This case also involves the Medicare fraction, so we follow the same course. See Brown v. Gardner, 513 U. S. 115, 118 (1994) (noting that the presumption of consistent usage is “surely at its most vigorous when a term is repeated within a given sentence”). We therefore conclude that an individual is “entitled to [SSI] benefits . . . under subchapter XVI” when she is eligi- ble to receive an SSI cash payment. And because eligibility is determined on a monthly basis, an individual is consid- ered “entitled to [SSI] benefits” for purposes of the Medicare Cite as: 605 U. S. ____ (2025) 9 Opinion of the Court fraction only if she is eligible for such benefits during the month of her hospitalization. III The hospitals advance two primary arguments for read- ing the phrase “entitled to [SSI] benefits . . . under subchap- ter XVI” more broadly. First, they characterize SSI benefits as encompassing noncash benefits for which eligibility is not determined on a monthly basis. Second, the hospitals, joined by the dissent, argue that eligibility for SSI benefits persists until a person must reapply for them, which occurs after 12 consecutive months of ineligibility for a cash pay- ment. See §1383(j)(1)(B). A As the hospitals see it, SSI benefits include both cash and noncash benefits—specifically, vocational rehabilitation services and continued Medicaid coverage.4 And a patient remains eligible for these benefits, the hospitals assert, even in months when the patient does not receive a cash payment. The hospitals’ theory stumbles out of the gate, because neither vocational rehabilitation services nor continued Medicaid coverage fits the description of a “supplementa[l] security income” benefit. §1395ww(d)(5)(F)(vi)(I) (emphasis added). And even beyond that self-evident point, none of these benefits is housed “under subchapter XVI.” Ibid. (em- phasis added). Begin with the hospitals’ reliance on the Ticket to Work and Self-Sufficiency Program. This program, which is available to people eligible for SSI benefits based on disa- bility or blindness, provides career development support and expanded employment opportunities through state —————— 4 In the court below, the hospitals pressed Medicare Part D’s prescrip- tion drug subsidy as another noncash SSI benefit. Because the hospitals have abandoned their reliance on that program, we do not address it. 10 ADVOCATE CHRIST MEDICAL CENTER v. KENNEDY Opinion of the Court agencies or private employment networks. See §1320b–19. Because subchapter XI establishes the Ticket to Work pro- gram, it is not a benefit “under subchapter XVI.” §1395ww(d)(5)(F)(vi)(I). Nor do any of subchapter XVI’s other references to voca- tional rehabilitation services confer an SSI benefit. Section 1382d(a), for example, requires the Commissioner to refer blind or disabled minors who receive SSI monthly cash pay- ments to the “appropriate State agency administering [a] State program under subchapter V” of the Social Security Act. The remainder of §1382d authorizes SSA to “reim- burse” state agencies that administer or supervise “voca- tional rehabilitation services approved under title I of the Rehabilitation Act of 1973.” §1382d(d). These express cross-references to subchapter V of the Social Security Act and title I of the Rehabilitation Act point to benefits housed elsewhere—not within subchapter XVI. The hospitals’ reliance on continued Medicaid coverage also fails. In most States, eligibility for SSI benefits quali- fies an individual for Medicaid health coverage. See §1396a(a)(10)(A)(i)(II). Thus, if a person earns excess in- come and loses her eligibility for SSI payments, she gener- ally also loses access to Medicaid. See ibid.; Baystate Med- ical Center v. Leavitt, 545 F. Supp. 2d 20, 37, n. 24 (DC 2008). Section 1382h(b) creates a limited exception to that default rule. It provides that “for purposes of subchapter XIX [governing Medicaid], any individual who was deter- mined to be a blind or disabled individual eligible to receive [an SSI] benefit under section 1382” and “who in a subse- quent month is ineligible for benefits under this subchap- ter” due to excess “income” is still “considered to be receiv- ing [SSI] benefits.” §1382h(b). According to the hospitals, the benefit of continued Medicaid coverage “arises solely out of section 1382h(b)” and therefore counts as an SSI ben- efit. Brief for Petitioners 37. The hospitals are mistaken. Section 1382h(b) does not Cite as: 605 U. S. ____ (2025) 11 Opinion of the Court create a supplemental security income benefit—it aids in the administration of the Medicaid program. (Hence the opening phrase of §1382h(b) states that the provision is “for purposes of subchapter XIX,” which governs Medicaid.) The provision merely allows certain blind or disabled people who are not eligible to receive SSI benefits in a given month to be treated as if they remain eligible for SSI benefits so that they can continue receiving Medicaid benefits. If con- tinued Medicaid coverage is an SSI benefit under subchap- ter XVI, this is a very odd way of establishing it. Under the hospitals’ theory, this provision confers an SSI benefit on people it simultaneously describes as “ineligible for [SSI] benefits.” §1382h(b). That defies common sense. B The hospitals, joined by the dissent, advance a second ar- gument: Eligibility, even for purely cash benefits, begins when a person enters the SSI system and continues until she has been ineligible for 12 consecutive months, at which point she must submit a new application for benefits. See post, at 7, 11–13 (opinion of JACKSON, J). To support this theory, the hospitals and the dissent em- phasize that when a person first applies for benefits, she must disclose her income “rate” “for the calendar year.” §1382(a)(1)(A); see post, at 11. True enough. But her “cal- endar year” income does not render her eligible for SSI ben- efits, nor does it establish that SSI benefits operate in in- tervals with a duration longer than one month. For that, she must still show that she meets the requirements for a given month. In fact, a nearby provision of the statute di- rects eligibility determinations “for a month” to be made “on the basis of the individual’s . . . income, resources, and other relevant characteristics in such month.” §1382(c) (empha- sis added). And while the dissent looks to §1383(a)(2)(B)(viii) for help, none is forthcoming. That the Commissioner may “defer (in the case of initial entitlement) 12 ADVOCATE CHRIST MEDICAL CENTER v. KENNEDY Opinion of the Court or suspend (in the case of existing entitlement)” a payment of a benefit, §1383(a)(2)(B)(viii), merely addresses a ques- tion of timing—it does not, as the dissent suggests, “con- template a longterm benefits relationship,” post, at 12. Nor does the reapplication requirement change the na- ture of eligibility. Under §1383(j)(1)(B), a once-eligible in- dividual must submit a new application after she has been “ineligible for benefits . . . for a period of 12 consecutive months.” Note that this provision does not say that an in- dividual remains eligible until this 12-month period has lapsed. On the contrary: It states that a person who “was an eligible individual” at one point must reapply after 12 consecutive months of ineligibility. §1383(j)(1)(A) (empha- sis added). As the D. C. Circuit observed, “it makes little sense to say that individuals are ‘entitled’ to the benefit in months when they are not even eligible for it.” 80 F. 4th, at 353.5 Leaning on Empire Health, which dealt with Medicare Part A, the hospitals and the dissent urge us to think of SSI benefits as an “income-insurance program.” Brief for Peti- tioners 41; see post, at 16–17. The shoe does not fit. Insur- ance programs generally “provid[e] basic protection against [certain future] costs,” including, in the case of Medicare Part A, “the costs of hospital, related post-hospital, home —————— 5 Moreover, this provision appears to be a housekeeping measure: Added roughly 14 years after SSI benefits were established, it ties the reapplication process to SSA’s longstanding practice of removing people from its database after 12 months of ineligibility. See 101 Stat. 3576; Tr. of Oral Arg. 60. Nor do other housekeeping provisions demonstrate that eligibility for SSI benefits is determined on something other than a monthly basis. See, e.g., §1383(e)(1)(B)(ii)(II)(bb) (ensuring SSA’s access to benefit recipient’s financial information until “the cessation of the re- cipient’s eligibility for benefits under this subchapter”); §1382c(a)(3) (H)(ii)(I) (requiring SSA to review, at least “once every 3 years,” “the con- tinued eligibility for benefits under this subchapter of each individual who has not attained 18 years of age and is eligible for such benefits by reason of an impairment . . . likely to improve”). Cite as: 605 U. S. ____ (2025) 13 Opinion of the Court health services, and hospice care.” §1395c (describing Med- icare Part A as an “insurance program”). SSI benefits, by contrast, do not provide an ongoing backstop against unex- pected costs—they operate as a welfare payment that di- rectly subsidizes recipients’ income. See Schweiker, 450 U. S., at 223 (describing SSI as “provid[ing] a subsistence allowance”); Bowen v. Galbreath, 485 U. S. 74, 75 (1988) (describing SSI as a “welfare program”). Notwithstanding these differences, the hospitals and the dissent insist that consistency with Empire Health requires us to reject HHS’s interpretation. See Brief for Petitioners 19–21; post, at 14–17. Recall that in Empire Health, we in- terpreted “ ‘entitled to [Medicare Part A] benefits’ ” to mean “all those qualifying for the program, regardless of whether they are receiving Medicare payments for part or all of a hospital stay.” 597 U. S., at 445 (quoting §1395ww(d)(5)(F)(vi)(I); alteration in original). So too here, the hospitals and the dissent assert: Being “entitled to [SSI] benefits” means that a patient is entitled to SSI benefits even if she does not qualify for a payment during the month of hospitalization.6 Yet rather than supporting this interpretation, Empire Health cuts against it. We defined the entitlement to ben- efits under Medicare Part A after carefully examining the prerequisites and characteristics of that particular benefit. See id., at 435–439. Medicare Part A, we observed, provides automatic and ongoing health insurance to individuals over the age of 65 or who have a chronic disability. Id., at 435– —————— 6 The dissent also criticizes our reading of the statute on the ground that it excludes from the Medicare fraction’s numerator certain patients who fail to receive payment during their month of hospitalization due to reasons unrelated to income. See post, at 9. But Congress’s decision to exclude certain individuals from eligibility for SSI benefits under sub- chapter XVI reflects that “the SSI program is broad in its reach, [but] its coverage is not complete.” Schweiker v. Wilson, 450 U. S. 221, 224 (1981). And again, we take no position on whether HHS has unreasonably ex- cluded particular codes from the Medicare fraction. 14 ADVOCATE CHRIST MEDICAL CENTER v. KENNEDY Opinion of the Court 436. And we explained that the Medicare Part A entitle- ment “never goes away” unless a beneficiary’s chronic “dis- ability diminishes,” and that “the stoppage of payment for any given service cannot be thought to affect the broader statutory entitlement to Part A benefits.” Id., at 437. For example, even if a patient “hit some limit on coverage” for eye care under Part A, the “policy [would] pay for more eye care in the next coverage period and meanwhile will pay for [a] knee replacement.” Ibid. Just as our decision in Empire Health turned on the spe- cific features of Medicare Part A, this case turns on the spe- cific features of SSI benefits under subchapter XVI. And a comparison of the two programs reveals critical distinc- tions. Again, while Medicare Part A benefits extend beyond specific payments for any given medical need, SSI benefits under subchapter XVI consist of monthly cash payments and nothing more. And while Medicare Part A’s entitle- ment is automatic and ongoing (with the exception of a dis- ability that diminishes), the SSI benefit is neither: Recipi- ents must apply for and be deemed eligible for benefits, and recipients can (and do) fluctuate in and out of eligibility de- pending on their income and resources from one month to the next. Consistency with Empire Health’s benefit-focused analysis thus requires us to recognize and give effect to the differences between Medicare Part A and SSI benefits. C Finally, invoking statutory purpose, the hospitals and the dissent insist that their interpretation of “entitled to [SSI] benefits . . . under subchapter XVI” best accords with “Con- gress’s ultimate goal [of] provid[ing] hospitals that serve the neediest among us with the appropriate level of critical funds.” Post, at 2. (Indeed, the dissent frames its argument as one primarily about the statute’s purpose and only sec- ondarily about its text.) They regard our reading as incon- sistent with the overall purpose of the Medicare fraction Cite as: 605 U. S. ____ (2025) 15 Opinion of the Court and DSH adjustment, because people who happen not to qualify for an SSI cash payment in a given month are un- likely to be any healthier or less costly to treat from one month to the next. As they see it, including these patients in the numerator of the Medicare fraction better measures a hospital’s burden, ensuring that the hospital receives “the appropriate level of critical funds.” Ibid. This argument overlooks that Congress chose a specific means to advance its end of better funding hospitals that care for a disproportionate percentage of needy Medicare patients. It could have chosen another. For instance, it could have captured the number of poor Medicare patients by relying on proof of annual income. (That measure might increase the numerator and therefore the reimbursement rate.) Alternatively, it could have more precisely isolated the expensive-to-treat Medicare patients by using not only their annual incomes, but also their health histories. (That measure might decrease the numerator and therefore the reimbursement rate.) But instead of choosing one of these (or some other) option, Congress decided to approximate a hospital’s share of expensive-to-treat Medicare patients by using the patient’s entitlement to SSI benefits under sub- chapter XVI. That is not a perfect measure of income—but neither is income a perfect measure of whether a patient is more costly to treat. In the end, the Medicare fraction and ultimate DSH adjustment reflect a balance of multiple com- peting interests, including increased funding for hospitals, administrability, efficiency, and allocation of finite re- sources. So yes, Congress sought to increase the reimbursement rate for hospitals that care for a disproportionate share of low-income Medicare patients. But as we have explained many times before, “[n]o statute pursues a single policy at all costs, and we are not free to rewrite this statute (or any other) as if it did.” Bartenwerfer v. Buckley, 598 U. S. 69, 81 (2023); Luna Perez v. Sturgis Public Schools, 598 U. S. 16 ADVOCATE CHRIST MEDICAL CENTER v. KENNEDY Opinion of the Court 142, 150 (2023) (“no law ‘ “pursues its . . . purpose[s] at all costs” ’ ” (alterations in original)); American Express Co. v. Italian Colors Restaurant, 570 U. S. 228, 234 (2013) (same); Kucana v. Holder, 558 U. S. 233, 252 (2010) (same); Rodri- guez v. United States, 480 U. S 522, 525–526 (1987) (per cu- riam) (same). We must determine how Congress chose to pursue its objective. Henson v. Santander Consumer USA Inc., 582 U. S. 79, 89 (2017) (“Legislation is, after all, the art of compromise, the limitations expressed in statutory terms often the price of passage”). And here, Congress made a specific choice: For purposes of the Medicare frac- tion, an individual is “entitled to [SSI] benefits” when she is eligible to receive an SSI cash payment during the month of her hospitalization. §1395ww(d)(5)(F)(vi)(I). We must respect the formula that Congress prescribed. * * * For the foregoing reasons, we affirm the judgment of the Court of Appeals. It is so ordered. Cite as: 605 U. S. ____ (2025) 1 JACKSON, J., dissenting SUPREME COURT OF THE UNITED STATES _________________ No. 23–715 _________________ ADVOCATE CHRIST MEDICAL CENTER, ET AL., PETITIONERS v. ROBERT F. KENNEDY, JR., SECRETARY OF HEALTH AND HUMAN SERVICES ON WRIT OF CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE DISTRICT OF COLUMBIA CIRCUIT [April 29, 2025] JUSTICE JACKSON, with whom JUSTICE SOTOMAYOR joins, dissenting. Providing quality healthcare to low-income patients can be costly. When Congress established Medicare’s hospital- reimbursement system, it recognized that people with low incomes tend to have comparatively worse health condi- tions and health outcomes than wealthier people, and was clear eyed about the fact that, as a result, “[h]ospitals that serve a disproportionate share of low-income patients have higher medicare costs.” H. R. Rep. No. 99–241, p. 16 (1985). To account for the variable costs attributable to the healthcare needs of different socioeconomic populations, Congress opted to reimburse hospitals that have a “dispro- portionate share” of low-income patients at a different (greater) rate than other hospitals. This case concerns the formula that Congress uses to identify and compensate those hospitals. The majority and I are in considerable agreement about key aspects of the statutory provision at issue. We agree that the point of the “disproportionate share” Medicare formula is to identify hospitals that serve a disproportionate number of low-income patients. We agree that the formula looks to the Supple- mental Security Income (SSI) program—a benefits program 2 ADVOCATE CHRIST MEDICAL CENTER v. KENNEDY JACKSON, J., dissenting for low-income Americans that entitles certain individuals to receive cash payments from the Government—and counts the number of a hospital’s Medicare-eligible patients who are also “entitled to” SSI. We agree that, under the SSI program, eligibility for a cash payment in a given month turns on a person’s monthly income. And we agree that, if the SSI program operates like Medicare Part A, our deci- sion in Becerra v. Empire Health Foundation, for Valley Hospital Medical Center, 597 U. S. 424 (2022), would con- trol the outcome of this case, and would require us to rule for the hospitals. All that said, the majority’s interpretation of Medicare’s disproportionate-share formula is based upon a fundamen- tal misunderstanding of how SSI’s cash-benefit program works. And that misunderstanding has led the majority to evaluate the Medicare statute without regard to the func- tion of the formula’s reference to the SSI program, causing it to reach the wrong conclusion. To be specific: When Congress created Medicare’s dis- proportionate-share formula, it looked to SSI’s cash- benefits program for a reason. No one disputes that Con- gress’s ultimate goal was to provide hospitals that serve the neediest among us with the appropriate level of critical funds. The only logical basis for the formula’s reliance on SSI, then, is to draw from that program’s pre-existing pool of individuals that have already been designated as our so- ciety’s neediest—not to assess the wholly irrelevant fact of whether any such individual actually received a cash pay- ment under the SSI program during the month of their hos- pitalization. The majority’s interpretation both ignores this critical context and endorses an interpretation of the Medi- care formula that arbitrarily undercounts a hospital’s low- income patients. In short, under the majority’s reading, Congress’s refer- ence to the SSI scheme in the Medicare statute serves no rational purpose. Worse still, the majority seems to think Cite as: 605 U. S. ____ (2025) 3 JACKSON, J., dissenting that a statutory formula specifically designed to authorize payments to certain hospitals in greater amounts is best read to affect the arbitrary denial of those additional funds. Respectfully, I dissent. I “The Medicare program provides Government-funded health insurance to over 64 million elderly or disabled Americans.” Empire Health, 597 U. S., at 428. The pro- gram generally works by reimbursing hospitals for their treatment of Medicare beneficiaries. See 42 U. S. C. §1395ww(d). To incentivize hospitals to treat patients in the most efficient manner, Congress reimburses hospitals for the services they provide at a fixed rate that turns on a patient’s diagnosis rather than the hospital’s actual costs. Empire Health, 597 U. S., at 429. But Congress also recognized that some hospitals have it harder than others. Based on empirical research, it specif- ically observed that “[h]ospitals that serve a disproportion- ate share of low-income patients have higher medicare costs,” and that this was so for two primary reasons. H. R. Rep. No. 99–241, at 16; see also Empire Health, 597 U. S., at 429. First, low-income patients tend to be in poorer health to begin with, and have more complications after medical procedures than patients who are wealthier. H. R. Rep. No. 99–241, at 16. Second, hospitals that see a signif- icant number of low-income patients often have to employ extra personnel, such as social workers and interpreters, in order to serve this population, adding to a hospital’s fixed costs. Ibid. Congress thus reasonably decided that those hospitals that have a disproportionate share of low-income patients should receive enhanced Medicare reimbursements. Em- pire Health, 597 U. S., at 429. And, notably, by compensat- ing for the disparity in treatment costs, Congress hoped to “encourag[e] hospitals to treat low-income patients.” Ibid. 4 ADVOCATE CHRIST MEDICAL CENTER v. KENNEDY JACKSON, J., dissenting To accomplish Congress’s fair-reimbursement objectives, the hospitals with a disproportionate share of low- income patients first had to be identified. One option would have been to require all hospitals to track their patients’ incomes and report them to the Government. H. R. Rep. No. 99–241, at 17. But this would have added administra- tive overhead to already burdened hospitals. Ibid. So, in- stead, Congress devised a formula that could be used to cal- culate the percentage of a hospital’s patients who are low income using administrative data already in the Govern- ment’s possession. See §1395ww(d)(5)(F)(vi). As the majority helpfully explains, part of that formula— referred to herein as the “Medicare fraction”—calculates the percentage of a hospital’s Medicare-eligible patients who have low incomes. The base of that fraction counts the total number of days Medicare patients spent in the hospi- tal. Ante, at 4. The numerator counts the number of days “ ‘attributable to Medicare patients who are poor,’ ” as deter- mined by their entitlement to SSI benefits. Ibid. We took this case to decide who falls within the numera- tor. That is, which hospital patients are “entitled to [SSI] benefits” for purposes of the disproportionate-share for- mula? §1395ww(d)(5)(F)(vi)(I). This seems like a narrow, technical question. But the stakes of the answer are quite high for hospitals because the greater the number of a hos- pital’s patients who fall within the numerator, the more Medicare-reimbursement money that hospital will receive. II The majority starts off on the right foot. “To determine when a person is ‘entitled to supplementary security income benefits,’ ” “we must know what the benefits are.” Ante, at 6 (quoting §1395ww(d)(5)(F)(vi)(I)). But it quickly mis- steps. According to the majority, because SSI entitles indi- viduals to “cash benefits,” and the eligibility for those ben- efits “is determined on a monthly basis,” ante, at 7, the Cite as: 605 U. S. ____ (2025) 5 JACKSON, J., dissenting Medicare fraction counts only those patients who are eligi- ble for a cash payment under SSI during the month of their hospitalization. This conclusion misunderstands both the benefit that SSI provides and also, importantly, the reason why Congress used SSI as its proxy for identifying low-in- come patients. A The regulations accompanying the SSI statute state that “[t]he basic purpose underlying the [SSI] program is to as- sure a minimum level of income for people who are age 65 or over, or who are blind or disabled and who do not have sufficient income and resources to maintain a standard of living at the established Federal minimum income level.” 20 CFR §416.110 (2024). We have likewise explained else- where that “[t]he SSI program establishes a federally guar- anteed minimum income for the aged, blind, and disabled.” Schweiker v. Hogan, 457 U. S. 569, 581–582 (1982). At a high level, the SSI program works as follows. Per- sons who are over 65, blind, or disabled may apply and will be enrolled in the SSI program if their annual income and financial resources are below a certain designated level. 42 U. S. C. §§1381, 1382(a)(1), (c)(7). Once approved—and un- til that enrollment is terminated—an individual who is en- rolled in the SSI program is guaranteed an annual income above the federal minimum. See §1382(b). This does not necessarily mean such an enrollee will receive a check from the Government each month (or even at all)—that depends on other specified factors. See §1382(c). But if in any month an enrollee’s income drops below the rate required to hit the federal minimum, the Government will pick up the slack by sending them a check. See ibid. I pause here to note that participation in the SSI program is thus highly beneficial to enrollees, regardless of whether they happen to need and receive a check in any particular month. This is so because being enrolled in SSI provides 6 ADVOCATE CHRIST MEDICAL CENTER v. KENNEDY JACKSON, J., dissenting participants with meaningful reassurance. Poverty in America is a plague of uncertainty marked by persistent in- stability—what others have called “the constant fear that it will get even worse.” M. Desmond, Poverty, By America 17 (2023). The problem is not just that one’s income is too low; it is that one’s income, such as it is, is highly volatile. “For scores of American workers, wages are . . . wobbly, fluctu- ating wildly not only year to year but month to month, even week to week.” Id., at 16. As one woman living on the edge of poverty described her situation: “ ‘[E]very day and every night when I’m trying to fall asleep, there’s this worry hang- ing. . . . How am I gonna get it done? How am I gonna stretch to get these bills paid? If one extra thing happens—.’ ” D. Shipler, The Working Poor 25 (2004). Congress understood this reality when it set out to con- struct an income-related social safety net for the population SSI covers. Indeed, the SSI program was specifically de- signed to address the often debilitating state of low-income volatility. If a person hovering at the poverty threshold is enrolled in the SSI program, she has peace of mind that if she misses work because her car breaks down, her child falls ill, or her work hours are suddenly slashed, she will still be able to pay the bills because the Government will provide her with some cash, if needed. That is the true “benefit” of SSI—one less thing to worry about. This basic understanding of the SSI program also helps to clarify the beneficiaries (i.e., it explains who is “entitled to” SSI benefits for purposes of that statutory scheme): an- yone who, per the threshold statutory criteria, is protected by SSI’s safety net in the first place. In other words, an “entitled” person is any individual who has a right to re- ceive SSI payments when his income falls below the federal minimum. The text and structure of the SSI statute plainly comport with this understanding of both the SSI benefit and what it Cite as: 605 U. S. ____ (2025) 7 JACKSON, J., dissenting means to be “entitled” thereto. The first substantive provi- sion of the SSI subchapter—notably titled “Basic entitle- ment to benefits”—makes a promise: “Every aged, blind, or disabled individual who is determined . . . to be eligible on the basis of his income and resources shall, in accordance with and subject to the provisions of this subchapter, be paid benefits.” §1381a (emphasis added; boldface deleted). That is clear enough. But which individuals are “eligible on the basis of [their] income and resources”? That question is answered by the subsequent provision, §1382(a), which ex- plains that any “aged, blind, or disabled individual” with an annual income and financial resources below a certain threshold “shall be an eligible individual for purposes of this subchapter.” Section 1382 then goes on to explain what an eligible in- dividual is eligible for under this program. Subsection (b) guarantees each eligible individual payments from the Gov- ernment up to the statutorily defined federal minimum in- come level over the course of a year, reduced by that indi- vidual’s countable income for that year. §1382(b). And subsection (c) provides that eligible individuals will receive a cash payment in any month in which their monthly in- come falls below the amount that would be required for them to earn the federal minimum over the course of a year. §1382(c)(1). Putting it all together: The SSI statute distinguishes be- tween an entitlement to be enrolled in the SSI program— promised in §1381a with eligibility criteria laid out in §1382(a)—and the right to receive a payment under the pro- gram. Anyone who is in the former bucket gets the quite valuable safety-net benefit of being enrolled in SSI (and the peace of mind that comes with it), whether or not they ac- tually receive a check from the Government in any particu- lar month. 8 ADVOCATE CHRIST MEDICAL CENTER v. KENNEDY JACKSON, J., dissenting B Because the majority fails to appreciate the program- matic nature of SSI, it reduces SSI’s benefit to the monthly check—and nothing more. From that premise, the majority concludes that all Congress cared about when measuring a hospital’s low-income population for purposes of Medicare’s disproportionate-share formula was the number of patients who received a check during the month of their hospital stay. But the majority also admits that the point of Medi- care’s disproportionate-share formula is to identify “ ‘hospi- tals serving an “unusually high percentage of low-income patients.” ’ ” Ante, at 2. And whether an individual received a check from the Government in a given month does not track—and, indeed, has little to do with—the broader “low- income” category of patients. The result is an interpreta- tion of the formula that not only strangely excludes indis- putably low-income patients, but does so arbitrarily. Imagine a woman who has been eligible for SSI payments for years and works at a retail store—I will call her Ann. In January, Ann picks up a few night shifts, which pay more than her usual day shifts. Cf. Shipler, The Working Poor, at 65. That extra income bumps her above the SSI cash- payment threshold so she does not get a payment in Janu- ary. But in February (and March, and April, and May), when her schedule returns to normal, her income falls back below the threshold. In the majority’s view, whether Ann counts as a low-income patient for purposes of the disproportionate-share formula depends on the happen- stance of her hospitalization. If she has a heart attack in February, she’s in. But if her heart fails in January, she’s out. Why would Congress have intended to exclude Ann from the hospital’s count of low-income patients in January but include her in February? The answer is simple: It didn’t. After all, the disproportionate-share formula is not about Ann’s own personal cash flow—Congress was not trying to Cite as: 605 U. S. ____ (2025) 9 JACKSON, J., dissenting identify those patients who lack cash on hand. Instead, as all agree, the formula is trying to count those patients who will be costlier to treat due to the health impacts of poverty. From the hospital’s (and society’s) perspective, there is no cost difference between treating Ann in January (when she had a bit more cash) or treating her in February (when she had a bit less). In either month, in terms of the hospital’s comparatively greater treatment costs, Ann qualifies as a low-income patient. The irrationality of the majority’s reading does not end there. Under the majority’s view, also falling outside the Medicare formula’s numerator are patients who happen to be hospitalized during the first month they are eligible for SSI, because, by statute, SSI payments do not kick in until the second month of eligibility. See §1382(c)(7). Other quirks of SSI’s statutory scheme—such as a provision pre- venting persons in Medicaid-funded nursing homes from getting an SSI payment in any month in which they have more than $30 in income, §1382(e)(1)(B)—likewise mean that many of the lowest-income patients are arbitrarily ex- cluded from the disproportionate-share formula’s count. Neither of these circumstances has anything whatsoever to do with how costly it will be to provide such patients with quality healthcare.1 The majority does not mention these incongruities, let alone justify them. Instead, it shrugs away all of the appar- ent oddities of its interpretation, blithely noting that “ ‘no —————— 1 The Government has at least conceded that its interpretation is not an “actual receipt” rule—a patient will be counted, the Government has promised, even if he doesn’t actually receive an SSI payment in a given month (e.g., because the enrollee moves or the post office loses the check), so long as he “satisfies the statutory requirements for a cash payment during the relevant month in question.” Tr. of Oral Arg. 51. The Gov- ernment also assured the Court that it would “retroactively” count pa- tients who initially failed to receive a payment in a given month due to an administrative error (such as an erroneous address on file) that was subsequently cured. Id., at 52. 10 ADVOCATE CHRIST MEDICAL CENTER v. KENNEDY JACKSON, J., dissenting statute pursues a single policy at all costs.’ ” Ante, at 15 (brackets omitted). I would think the People’s representa- tives deserve more credit than to have this Court conclude they intentionally enacted a statute that does not reach its aims and operates so arbitrarily that it makes no sense. In the majority’s view, my way of analyzing the relevant statutes impermissibly elevates purpose over text, because it “overlooks that Congress chose a specific means to ad- vance its end.” Ante, at 15. But that contention simply begs the question before us; what we are doing now is trying to discern what it was that Congress “chose” when it refer- enced the SSI program while crafting the Medicare fraction. The majority apparently believes it can figure that out without considering what the Medicare fraction was de- signed to accomplish—it just insists, largely by ipse dixit, that Congress “chose” a proxy for low-income status that asks whether a patient received an SSI check during the month of their hospital stay. Ante, at 8–9, 15. My response is simply, why would Congress possibly make that choice? The illogic of the majority’s interpretation strongly signals that what the majority believes Congress “chose” is not ac- tually what Congress intended or accomplished. There is also no need to conclude that Congress intention- ally selected such an irrational and arbitrary measurement when there is another equally (if not more) plausible inter- pretation available: that Congress intended to count those patients who were enrolled in the SSI program at the time the hospital served them. Statutes “are not inert exercises in literary composition,” but “instruments of government.” United States v. Shirey, 359 U. S. 255, 260 (1959). We dis- respect that instrument—and the coequal branch of Gov- ernment that has enacted it—when we fail to understand, or appreciate, the logic of the laws Congress designs. Cite as: 605 U. S. ____ (2025) 11 JACKSON, J., dissenting C There is yet another reason the majority’s myopic ap- proach to interpreting statutes has yielded the wrong result in this case. As the majority envisions the SSI program, a patient’s entitlement to SSI toggles off and on each month, depending on her cash flow. That view of how the program operates is flatly inconsistent with the fully contextualized reading that I have laid out in Part II–A. It also conflicts with the statute’s plain text, which clearly contemplates an SSI entitlement that extends beyond a single month. To understand how the majority goes awry on this point, start where the majority does: with the language of §1382(c)—a provision that explains how and when SSI cash benefits will be paid. See ante, at 7. By starting there, the majority essentially ignores §§1382(a) and (b), which plainly address who is entitled to SSI benefits and what they are qualified to receive due to that entitlement. See also Schweiker v. Wilson, 450 U. S. 221, 223, n. 2 (1981) (“To be eligible for SSI benefits,” a person’s “income and re- sources must be below the levels specified in . . . 42 U. S. C. §1382(a)”); Sullivan v. Zebley, 493 U. S. 521, 524 (1990) (“A person is eligible for SSI benefits if his income and financial resources are below a certain level, §1382(a), and if he is ‘disabled’ ”). Moreover, and importantly for present pur- poses, subsection (a) eligibility looks to an individual’s in- come over the course of a “calendar year”—not her income in any particular month. §1382(a)(1)(A). Thus, the text of this statute, read as a whole, plainly establishes that eligi- bility for SSI benefits operates on a longer time horizon than the majority acknowledges. Other provisions further demonstrate that whether someone is “entitled to” SSI benefits does not turn on their income in a single month. After an individual applies for SSI and is deemed eligible under §1382(a), she need not ap- ply again the next month—or, actually, any month thereaf- 12 ADVOCATE CHRIST MEDICAL CENTER v. KENNEDY JACKSON, J., dissenting ter—because her eligibility for benefits lasts until her in- come is too high for one full year, §1383(j)(1); 20 CFR §416.1335, or until her enrollment is terminated for some other reason, §1383(e)(1)(A); 20 CFR §§416.1331, 416.1333– 416.1334. The statute also seems to contemplate a long- term benefits relationship, insofar as it permits the Depart- ment of Health and Human Services (HHS) in certain cir- cumstances to “defer (in the case of initial entitlement) or suspend (in the case of existing entitlement)” SSI benefits— a distinction that only makes sense if an individual’s enti- tlement to SSI lasts beyond a single month. §1383(a)(2)(B)(viii) (emphasis added); see also §1382c(a)(3)(H)(ii)(I) (referring to an individual’s “contin- ued eligibility” for benefits over the course of multiple years). If all that is still not enough to permit the majority to ac- curately discern the broader confines of this program, con- sider the fact that HHS requires SSI applicants to grant the agency permission to access their financial records so that HHS can automatically monitor their income. §1383(e)(1)(B)(ii); 20 CFR §416.207. That authorization lasts until “the cessation of the recipient’s eligibility for ben- efits under this subchapter.” §1383(e)(1)(B)(ii)(II)(bb). But if eligibility for SSI benefits were a monthly determination, the give-us-your-records provision would accomplish noth- ing. It would do the agency no good to have permission to access those records for one month and one month only. The practical realities of SSI administration further demonstrate that the SSI entitlement is not determined month by month. For example, SSI benefits are paid on the first day of the month—an individual receives his February payment on February 1st. 20 CFR §416.502. With its month-only entitlement perspective, the majority thus ap- parently surmises that HHS regularly pays benefits with- out knowing whether the recipient is eligible for SSI at all. Any such policy would be surprisingly irresponsible. But if Cite as: 605 U. S. ____ (2025) 13 JACKSON, J., dissenting SSI is a program that lasts beyond a single month, day-one payments are both rational and administratively feasible. Recall that we are talking about people who are desperately in need of cash to pay their monthly bills; this explains the agency’s practice of providing prompt, prospective pay- ments, which the aforementioned income monitoring facili- tates. Moreover, as I have explained, once an individual is approved for SSI, he is entitled to receive such prospective payments, as needed, until his enrollment is terminated. By adopting a broader time horizon than the single month in which the payment is made, the agency can get the money out to the needy individual and then subsequently smooth out any over- (or under-) payments it makes, by checking the person’s actual salary for the month in ques- tion and, if necessary, adjusting the amount it pays in later months. See §1383(b). The majority simply ignores these kinds of programmatic features that cut against its reading. And the unhelpful statutory provisions that the majority does acknowledge get short shrift in its opinion; in a footnote, the majority bats them away as mere legislative “housekeeping.” Ante, at 12, n. 5. I grant that it is easier to duck Congress’s handiwork than to explain the implications of its various policy choices. But if the majority is going to base its interpretation exclu- sively on what Congress “chose” when it used the term “el- igibility,” it must grapple with all such usages of that term in the statute in question—not just those that support its preferred reading.2 Notably, the design of the statute that creates the SSI program—basic criteria establishing an entitlement to a —————— 2 For my part, I do not deny that the SSI statute discusses an individ- ual’s “ ‘eligibility for a benefit . . . for a month.’ ” Ante, at 7 (quoting §1382(c)(1)). But, as I’ve explained, that monthly eligibility is meant only to describe the benefit (i.e., the cash payment) that an individual who is entitled to SSI is eligible to receive. Supra, at 7. 14 ADVOCATE CHRIST MEDICAL CENTER v. KENNEDY JACKSON, J., dissenting benefit, pursuant to which individuals are eligible for a pay- ment under certain conditions that are delineated else- where—is not unique to SSI. Consider veterans benefits, for example. A veteran “with the requisite period of mili- tary service becomes ‘entitled to’ ” certain educational bene- fits, “typically in the form of a stipend or tuition payments.” Rudisill v. McDonough, 601 U. S. 294, 299 (2024) (emphasis added). But just because a person is entitled to those ben- efits does not mean she will ever receive them; there are hoops through which she must jump and conditions she must satisfy to be eligible to receive a payment. Id., at 300– 301. Or consider Medicare Part A. “When a person turns 65,” she “becomes ‘entitled’ to” Medicare Part A benefits. Em- pire Health, 597 U. S., at 428 (quoting 42 U. S. C. §§426(a)– (b)). There, too, entitlement does not guarantee payment— a person may be entitled to Medicare Part A benefits yet never receive a single cent, perhaps because he is covered by private health insurance, or because he has hit some statutory cap on care. 597 U. S., at 432. As this Court has recognized, “[t]he entitlement to [Medicare Part A] bene- fits” is simply “an entitlement to payment under specified conditions.” Id., at 436 (some emphasis deleted). The same is true of SSI. Compare §426(c)(1) (explaining that “entitle- ment of an individual” to Medicare Part A benefits “con- sist[s] of entitlement to have payment made under, and subject to the limitations in, part A”) with §1381a (stating that “[b]asic entitlement to [SSI] benefits” consists of a promise to certain individuals of payment “in accordance with and subject to the provisions of th[e SSI] subchapter” (boldface deleted)). III It was precisely this distinction—between a threshold en- titlement to participate in a benefit program, on the one Cite as: 605 U. S. ____ (2025) 15 JACKSON, J., dissenting hand, and a subsequent right to a payment under that pro- gram, on the other—that was the linchpin of our interpre- tation of another part of the disproportionate-share formula just three Terms ago. In Empire Health, we faced a ques- tion that is substantially similar to the one the Court de- cides today: Which patients are “ ‘entitled to’ ” Medicare Part A benefits for purposes of the disproportionate-share formula? 597 U. S., at 428. What is more, the arguments in that case mirrored the arguments we consider now. One side maintained that a patient is “entitled to” such benefits only if she had actually received a Medicare payment; the other insisted that a patient is so entitled if he was eligible for the Medicare Part A program, no payment necessary. See id., at 432–433. Notably, however, the valence of the arguments was flipped—in Empire Health, it was the hos- pitals that insisted payment was required, while the Gov- ernment asserted program eligibility sufficed. Ibid. We sided with the Government. A patient is “ ‘entitled to’ ” Medicare Part A benefits, we held, if she “meet[s] the basic statutory criteria” for the Medicare Part A program, whether or not she “actually receiv[ed] payment for a given day’s treat- ment.” Id., at 435. For purposes of the disproportionate-share formula, we said, a patient’s receipt of payment is beside the point. All the formula cares about is whether a patient qualifies for the program that entitles her to payment un- der specified conditions. Id., at 436. Exactly that same logic should have carried the day here. A patient is “entitled to” SSI benefits for purposes of the disproportionate-share formula if she “meets the basic stat- utory criteria” for the SSI program, whether or not she “ac- tually receiv[ed an SSI] payment” in the relevant month. Id., at 432, 435. In other words, just as with Medicare Part A, statutory entitlement to SSI “coexists with limitations on payment.” Id., at 436. Our reasoning in Empire Health resulted in hospitals re- ceiving less money by operation of the Medicare fraction. 16 ADVOCATE CHRIST MEDICAL CENTER v. KENNEDY JACKSON, J., dissenting Id., at 444. Applied here, that same logic requires them to receive more, because it places more patients in the numer- ator of the Medicare fraction. But instead of simply follow- ing Empire Health where it leads, the majority diverges from its clear and plainly applicable holding. In the major- ity’s view, although a patient need not receive a Medicare Part A payment to be “entitled to” Medicare Part A for pur- poses of the disproportionate-share formula, she must re- ceive an SSI payment to be “entitled to” SSI under that same calculation. To justify this puzzling departure, the majority identifies two “critical distinctions” that it says distinguish SSI from Medicare Part A and thus make this case different from Empire Health. Ante, at 14. First, the majority says that Medicare Part A benefits “extend beyond specified pay- ments for any given medical need,” whereas SSI benefits “consist of monthly cash payments and nothing more.” Ibid. I’ve already explained why that characterization of SSI is wrong: The SSI benefit is not simply the payment itself, but the promise of a payment in one’s time of need. Supra, at 5–6. SSI thus operates just like income insur- ance. Enrolled individuals are promised a payout, should the relevant triggering event—monthly income below the threshold—occur. The majority rejects this commonsense conclusion based on superficial mischaracterizations of the SSI program and what it means to the people who rely on it. So, SSI is com- monly described as a “ ‘welfare program,’ ” ante, at 13—so what? That label does not change the fact that this welfare program operates more like insurance than a subsidy. The majority also seems to believe that insurance programs may protect beneficiaries only against increased costs—not decreased income. Ibid. But why is that the case? Econom- ically speaking, increased costs and decreased income are two sides of the same coin. The only difference is the pre- cipitating factor, and, of course, the fact that the decreased- Cite as: 605 U. S. ____ (2025) 17 JACKSON, J., dissenting income species of insurance acknowledges the reality of in- come insecurity. The second declared distinction is the majority’s conten- tion that Medicare Part A is “automatic and ongoing” while SSI is not. Ante, at 14. This seems faulty from the start, since the majority concedes that disabled individuals can lose their entitlement to Medicare Part A if their disability diminishes. Ibid. Thus, it is questionable whether Medi- care Part A is, in fact, “ongoing.” In any event, the majority fails to explain why this “ongoing” distinction makes any difference. The question before us is whether a person is “entitled to” SSI for purposes of the disproportionate-share formula, not whether a person must reapply to become so entitled, or whether it is possible to be excised from this benefit program’s rolls. Ultimately, then, neither of the “critical” distinctions that the majority identifies between Medicare Part A and SSI are critical at all. So, in the absence of any principled basis for distinguishing this case from Empire Health, the major- ity falls back on pithy rhetoric, quipping that “ ‘it makes lit- tle sense to say that individuals are “entitled” to the benefit in months when they are not even eligible for it.’ ” Ante, at 12. Again, this characterization misrepresents the real benefit of SSI. It is also noteworthy that, while some on this Court embraced a similar argument in Empire Health, they did so in dissent. See 597 U. S., at 447–448 (opinion of KAVANAUGH, J.) (arguing that a patient could not be con- sidered “entitled to” a Medicare Part A benefit “if the pa- tient by statute could not” receive a payment). The majority view in Empire Health fully appreciated the insurance-like nature of the Medicare program, and its reasoning applies full bore to the question we address today. * * * The decision the majority has made in this case will de- 18 ADVOCATE CHRIST MEDICAL CENTER v. KENNEDY JACKSON, J., dissenting prive hospitals serving the neediest among us of critical fed- eral funds that Congress plainly attempted to provide. Hos- pitals that have a disproportionate share of low-income pa- tients are struggling. Indeed, it is undisputed that systemically undercounting low-income patients for the purposes of the disproportionate-share formula might cause many such hospitals to close their doors entirely, such that patients from our Nation’s poorest communities may not be served at all. Brief for American Hospital Associa- tion et al. as Amici Curiae 27–28; Tr. of Oral Arg. 36–38. This outcome is not compelled by the text of the Medicare statute or the circumstances that surround it. Rather, it is, unfortunately, directly attributable to the majority’s incu- rious and context-free method of statutory analysis. Con- gress’s reference to the SSI program in the Medicare for- mula has confused the majority into thinking that Congress meant for hospitals serving low-income patients to be reim- bursed at lower rates than if their patient population was fully taken into account. So it will now be up to Congress to restate its intention that low-income people have access to quality medical care and that hospitals be compensated accordingly. I suspect that such a legislative fix would not be too diffi- cult to craft. But Congress would not need to go that extra mile if this Court’s interpretive practices would just take care to evaluate the text of a statute alongside any indis- putable legislative objectives. Here, we should have easily concluded that, for purposes of the disproportionate-share formula used to reimburse hospitals, patients are “entitled to” SSI benefits when they are eligible for and enrolled in the SSI program, as Congress undoubtedly intended. 7-2 in favor of the Department of Health and Human Services in a case that challenged how HHS applied Congress’ formula for calculating Medicare Disproportionate Share Hospital payments. The formula includes a fraction that counts supplemental security income-eligible Medicare beneficiaries in the numerator and the total Medicare-eligible population in the denominator. The court upheld HHS’s longstanding position that if a patient is ineligible for a monthly cash benefit under SSI, a hospital cannot count that person towards the SSI portion of its DSH fraction.  
 
The AHA last year filed an amicus brief in the case, arguing that HHS was undercounting the number of SSI-eligible Medicare beneficiaries by claiming patients are “entitled to” SSI benefits only if they actually receive SSI benefits, which lowers the numerator in the formula and results in smaller payments.