Brooks v. Walker County Hosp. Dist.

• Citation: 688 F.2d 334
• Decision Date: 04 October 1982
• Docket Number: No. 82-2044,82-2044
• Parties: Mozell and Delores BROOKS, et al., Plaintiffs-Appellants, v. WALKER COUNTY HOSPITAL DISTRICT, et al., Defendants-Appellees. Summary Calendar.
• Court: United States Courts of Appeals. United States Court of Appeals (5th Circuit)

Page 334

688 F.2d 334

Mozell and Delores BROOKS, et al., Plaintiffs-Appellants, v. WALKER COUNTY HOSPITAL DISTRICT, et al., Defendants-Appellees.

No. 82-2044

Summary Calendar.

United States Court of Appeals Fifth Circuit.

Oct. 4, 1982.

Jane K. Swanson, Conroe, Tex., Curtis B. Stuckey, Nacogdoches, Tex., for plaintiffs-appellants.

Joe B. Henderson, Jr., Huntsville, Tex., for defendants-appellees.

Appeal from the United States District Court for the Southern District of Texas.

Before CLARK, Chief Judge, RANDALL and JOHNSON, Circuit Judges.

RANDALL, Circuit Judge:

Plaintiffs Mozell Brooks, Delores Brooks and Tee Massie ¹ brought this 42 U.S.C. § 1983 action individually and on behalf of a proposed class of all other medically needy indigent residents of the Walker County Hospital District against the District and its Board of Managers. Plaintiffs alleged that they were denied without due process of law an entitlement to free medical services they claim is guaranteed them by Article IX, § 9 of the Texas Constitution. ² The district court dismissed the action on the grounds that this was a proper case for Pullman abstention. ³ We agree with the district court and therefore affirm.

As alleged in their pleadings, each of the plaintiffs is an indigent and medically needy resident of the Walker County Hospital District. Plaintiffs Mr. and Mrs. Brooks are physically unable to work due to medical problems. Mrs. Brooks suffers from diabetes and is in continuous need of insulin; she also suffers from heart problems, gall bladder problems, and other medical difficulties. Plaintiff Massie is unable to afford medicine which has been prescribed for him. Massie was previously hospitalized within the hospital district but was not informed of his right to free medical care. As a result he has at present over $600 in unpaid hospital and physicians' bills, some of which will not be covered by Medicare. Massie was informed by a hospital social worker that Massie's $200 hospital bill would not be written off as part of the hospital's indigent care obligation because it was a Medicare deductible amount.

As alleged in plaintiffs' complaint, defendants have failed and refused to institute any system whatsoever for providing or paying for necessary medical care other than hospital care. Defendants have also failed to institute orderly, consistent, and rational policies and procedures for the provision of free hospital and medical care to the low income residents of the district, and to give proper and effective notice of the availability of such care.

Pullman abstention is a judge-made doctrine which postpones the exercise of federal jurisdiction in order to clarify ambiguous state law issues in the state courts when resolution of such issues might eliminate or substantially modify a federal constitutional question. Railroad Commission of Texas v. Pullman Co., 312 U.S. 496, 61 S.Ct. 643, 85 L.Ed. 971 (1941). We believe that the district court properly exercised its discretion in ordering abstention in this case. ⁴ Plaintiffs present a claim for denial of a property right without due process of law. That property right is an entitlement to free medical services which plaintiffs claim is granted them by the Texas Constitution. There is of course no question here of an attack on state law as inconsistent with the Federal Constitution. But the scope and extent of the entitlement is essential to disposition of the plaintiffs' claims, and this fact makes abstention appropriate, as we now discuss.

We begin by noting that the ambiguity of state law required for invocation of Pullman abstention definitely exists in this case. We do not share plaintiffs' views about the clarity of the mandate of Article IX, § 9 of the Texas Constitution. The fact that hospital districts are established with "full responsibility for providing medical and hospital care to needy inhabitants" might be read to require free services, as plaintiffs contend, but it might also be read to require only that such services be provided at a reduced rate commensurate with the patient's ability to pay. Cf. Ibarra v. Bexar County Hospital District, 624 F.2d 44 (5th Cir. 1980) (describing hospital district's interpretation of Article IX, § 4); Tex.Rev.Civ.Stat.Ann. art. 4487 (Vernon 1976). Moreover, medical and hospital care covered in the entitlement may extend to some types of treatment and not others. It is possible that the Texas Constitution mandates responsibility to pay for Mrs. Brooks' insulin, for example, but not other medical services she seeks in her complaint. In addition, a distinction might rationally be made between emergency and non-emergency services. We express no opinion on how these questions should be resolved. We merely seek to point out that the bare language of Article IX, § 9 creates an entitlement of uncertain scope and extent.

Plaintiffs have pointed to several opinions of the Attorney General of Texas which have discussed Article IX § 9, but we do not find these to clarify markedly the difficult issues presented here. No authoritative construction of the nature of the entitlement has emerged from the Texas courts. ⁵ Moreover, a full treatment of the scope of the entitlement created by state law must necessarily consider the effects of enabling legislation for hospital districts, as well as any regulatory framework established for administration of the districts. "(W)here the challenged statute is part of an integrated scheme of related constitutional provisions, statutes, and regulations, and where the scheme as a whole calls for clarifying interpretation by the state courts," the Supreme Court has regularly required abstention. Harris County Commissioners Court v. Moore, 420 U.S. 77, 84-85 n.8, 95 S.Ct. 870, 875-876 n.8, 43 L.Ed.2d 32 (1977); (citing Reetz v. Bozanich, 397 U.S. 82, 90 S.Ct. 788, 25 L.Ed.2d 68 (1970); Meridian v. Southern Bell Tel. & Tel. Co., 358 U.S. 639, 79 S.Ct. 455, 3 L.Ed.2d 562 (1959)).

Plaintiffs argue that even if the scope of the entitlement is unclear, the federal constitutional question of denial of due process cannot be avoided no matter how the entitlement is construed. Of course it is possible that no entitlement to completely free medical services might exist at all based on the State's construction of its constitution. But let us accept arguendo that some form of entitlement to some form of medical care must exist under any reasonable construction of the constitution and related statutory and regulatory provisions. To the extent that the plaintiffs' claim is that they were denied notice and a hearing on their ability to qualify for free (or less expensive) medical care (regardless of whether they would, after a hearing, be found to qualify for such care), their argument has some force. Yet it is an axiom of due process jurisprudence that the type of process which is due turns upon the nature of the entitlement and an analysis of the governmental and private interests affected. E.g., Mathews v. Eldridge, 424 U.S. 319, 96 S.Ct. 893, 47 L.Ed.2d 18 (1976); Morrissey v. Brewer, 408 U.S. 471, 92 S.Ct. 2593, 33 L.Ed.2d 484 (1972); Goldberg v. Kelly, 397 U.S. 254, 90 S.Ct. 1011, 25 L.Ed.2d 287 (1970). Thus, even given the fact that federal constitutional issues must necessarily arise in the disposition of this case, we think clarification of the nature of the entitlement may have a considerable impact on the posture and ultimate resolution of those federal issues. It is well settled that Pullman abstention may be appropriate in such cases in addition to those cases where the federal claims may be thoroughly mooted through a narrowing construction of state law. E.g., Palmer v. Jackson, 617 F.2d 424 (5th Cir. 1980).

Plaintiffs insist nevertheless that abstention is frowned upon in § 1983 cases, and that abstention in this case will work an undue hardship on them. We are not unsympathetic to either of these arguments. However, we think that on balance, strong policy reasons militate in favor of abstention. We deal here with a question of considerable local importance. It is an issue which may have a significant financial impact on the State of Texas as well as on its indigent inhabitants, and it is an issue touching upon a sensitive area of state policy. The fact that it also involves construction of the State's own constitution merely enhances its local importance. Harris County Commissioner's Court, supra; Reetz, supra. The better course, we think, is to allow the Texas courts the first opportunity to address the difficult questions of state health care law and policy raised by plaintiffs' suit. Cf. Ibarra, supra (abstention proper in § 1983 case to determine if under state constitution county hospital districts must treat indigent aliens and legal residents alike with respect to non-emergency medical services). The judgment of the district court is affirmed.

AFFIRMED.

1 A fourth plaintiff in the original action, Edwina Bicknell, is now deceased.

2 Tex.Const. art....