678
Thomas, J., concurring in judgment
of discerning one "purpose" from the Medicaid Act. If, as the plurality reasons, the " 'best interests' " of Medicaid beneficiaries require that access to prescription drugs not be "severely curtailed," then § 1396r-8(d)(2) empowers States to do what the plurality believes is precisely opposed to the best interests of Medicaid beneficiaries. This is just a further illustration of the compromises embodied in the Medicaid Act and demonstrates the impossibility of defining "pur-poses" in complex statutes at such a high level of abstraction and the concomitant danger of invoking obstacle pre-emption based on the arbitrary selection of one purpose to the exclusion of others.
In light of the broad grant of discretion to States to impose prior authorization, petitioner cannot produce a credible conflict between Maine Rx and the Medicaid Act. Both the plurality and the dissent fail to explain how a State's purpose (and there may be many) in enacting a prior authorization program makes any difference in determining whether that program is in the "best interests" of Medicaid beneficiaries. The mere existence of a prior authorization procedure, as contemplated by § 1396r-8(d)(5), cannot "severely curtai[l]" access to prescription drugs (the Court's touchstone for a "conflict" with § 1396a(a)(19), ante, at 665). Otherwise the plurality has rendered an interpretation of the Medicaid Act that leaves it with an internal conflict.
The dissent reasons that prior authorization programs must "safeguar[d] against unnecessary utilization," post, at 685 (O'Connor, J., concurring in part and dissenting in part) (internal quotation marks omitted), of prescription drugs and
ments as to whether a drug should be covered. See, e. g., § 1396r- 8(d)(2)(B) (fertility drugs), § 1396r-8(d)(2)(C) (cosmetic purposes). Again, this begs the question of why, for example, Congress would give States greater authority over the decision whether or not to cover a prescription hair growth drug than whether or not to subject the same hair growth drug to prior authorization.
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