Children's Healthcare is a Legal Duty v. Vladeck, Civil No. 3-96-63.

• Citation: 938 F. Supp. 1466
• Decision Date: 07 August 1996
• Docket Number: Civil No. 3-96-63.
• Parties: CHILDREN'S HEALTHCARE IS A LEGAL DUTY, INC., a corporation under the laws of Iowa; Bruce Bostrom; and Steven Petersen, Plaintiffs, v. Bruce C. VLADECK, in his capacity as director of Health Care Finance Administration, an agency of the United States; and Donna Shalala, in her official capacity as Secretary of the United States Department of Health and Human Services, an agency of the United States, Defendants, and The First Church of Christ, Scientist, Boston, Massachusetts, Defendant-Intervenor. Minnesota Civil Liberties Union, Amicus Curiae.
• Court: U.S. District Court — District of Minnesota

938 F. Supp. 1466

CHILDREN'S HEALTHCARE IS A LEGAL DUTY, INC., a corporation under the laws of Iowa; Bruce Bostrom; and Steven Petersen, Plaintiffs, v. Bruce C. VLADECK, in his capacity as director of Health Care Finance Administration, an agency of the United States; and Donna Shalala, in her official capacity as Secretary of the United States Department of Health and Human Services, an agency of the United States, Defendants and The First Church of Christ, Scientist, Boston, Massachusetts, Defendant-Intervenor Minnesota Civil Liberties Union, Amicus Curiae.

Civil No. 3-96-63.

United States District Court, D. Minnesota, Third Division.

August 7, 1996.

COPYRIGHT MATERIAL OMITTED

Robert J. Bruno, Burnsville, MN, for Plaintiffs.

Friedrich A.P. Siekert, Assistant United States Attorney, Minneapolis, MN, Sheila M. Lieber and Joseph W. LoBue, Civil Division, Department of Justice, and Lorie Mayorga, Office of the General Counsel, Department of Health and Human Services, of counsel, Washington, DC, for Defendants.

Stephen M. Shapiro, Kenneth S. Geller, and Michael W. McConnell, Mayer, Brown & Platt, Chicago, IL, and Terrence J. Fleming and Ansis V. Viksnins, Lindquist & Vennum P.L.L.P., Minneapolis, MN, for Defendant-Intervenor.

Gary D. Ansel, Reinhardt and Anderson, Saint Paul, MN, for Minnesota Civil Liberties Union, amicus curiae.

MEMORANDUM OPINION AND ORDER

KYLE, District Judge.

Introduction

Plaintiffs challenge the constitutionality of certain exemptions for Christian Science sanitoria under Medicare and Medicaid, claiming that Congress' creation of such exemptions violates the Establishment Clause of the First Amendment. Plaintiffs have filed a Motion for Summary Judgment, and both Defendants and Defendant-Intervenor The First Church of Christ, Scientist ("the Church") have submitted Cross-Motions for Summary Judgment. For the reasons set forth below, the Cross-Motions brought by Defendants and the Church will be denied and Plaintiffs' Motion for Summary Judgment will be granted.

Background

The relevant facts are largely undisputed. The First Church of Christ, Scientist was founded by Mary Baker Eddy in 1879 and has grown to include nearly 3,000 congregations worldwide. Fleming Supp.Aff., Ex. T, at 278-79; Swan Aff. ? 3. A primary tenet of Christian Science is the belief that disease is caused by sin and mortal frailties; accordingly, physical healing is believed to be dependent on prayer instead of medical technology. Fleming Supp. Aff., Ex. T, at 279. A Christian Scientist is not rigidly compelled by the Church to employ purely spiritual means for healing; yet the concept of spiritual healing is central to the religion. Id. Christian Science practitioners of spiritual healing are certified by the Church and listed in the Christian Science Journal, a periodic publication of the Church. Id.; Swan Aff. ? 7. The Church has established a process for certifying sanitoria which practice Christian Science healing methods; although Christian Science does not teach that medical care will cure the body, it is undisputed that these institutions provide bed and board as well as general personal care. See, e.g., HCFA Christian Science Supplement ?? CS-200(D); 204(A).

Plaintiffs' Challenges to Medicare Act Exemptions

Part A of the Medicare Act, 42 U.S.C. ?? 1395 et seq., creates a comprehensive health insurance program for the aged and disabled. The Act pays for hospital care and for post-hospitalization care provided by skilled nursing facilities, home health agencies, and hospices. 42 U.S.C. ? 1395c. Payments under the Act are financed through a federal income tax on self-employment income (the Self-Employment Contributions Act) and federal employment taxes on wages paid to employees (mainly under the Federal Insurance Contributions Act, or "FICA"). Part B of the Medicare Act establishes a voluntary insurance program providing supplementary coverage for other medical expenses, such as physicians' fees and outpatient therapy. See 42 U.S.C. ? 1395j, 42 U.S.C. ? 1395k.

Plaintiffs challenge certain subsections and regulations of Part A of the Medicare Act which provide for the payment of nursing care and related services in Christian Science sanitoria. They note that most providers of health care under the Medicare Act are required to meet statutory and regulatory standards from which Christian Science sanitoria are exempted, and these exemptions form the basis of their claim under the Medicare Act.

First, Plaintiffs challenge the inclusion of Christian Science sanatoria in the Medicare Act definition of "hospital" in 42 U.S.C. ? 1395x(e):

The term "hospital" also includes a Christian Science sanatorium operated, or listed and certified, by the First Church of Christ, Scientist, Boston, Massachusetts, but only with respect to items and services ordinarily furnished by such institution to inpatients, and payment may be made with respect to services provided by or in such an institution only to such extent and under such conditions, limitations, and requirements (in addition to or in lieu of the conditions, limitations, and requirements otherwise applicable) as may be provided in regulations.

Similarly, Plaintiffs challenge the inclusion of sanitoria in the definition of "skilled nursing facility" under 42 U.S.C. ? 1395x(y)(1), which essentially mirrors the language quoted above. These provisions allow sanitoria to be eligible for benefits flowing from the Medicare and Medicaid programs.

Next, Plaintiffs challenge the exemption of Christian Science sanitoria from the requirements of 42 U.S.C. ? 1320c. This section requires "quality control peer review organizations" to review the performance of physicians in the area, 42 U.S.C. ? 1320c-3, requires practitioners to assure their patients that services will be provided in an economically efficient manner and only when medically necessary, 42 U.S.C. ? 1320c-5, and sets limits on the disclosure of patient information, 42 U.S.C. ? 1320c-9. However, "the provisions of this part shall not apply with respect to a Christian Science sanitorium operated, or listed and certified, by the First Church of Christ, Scientist, Boston, Massachusetts." 42 U.S.C. ? 1320c-11. The accompanying regulations also exempt Christian Science sanitoria from the more detailed regulatory requirements of peer review organizations. 42 C.F.R. ? 466.1.¹ Absent the provisions allowing sanitoria to come within the definition of "hospital" and "skilled nursing facility," and absent the provisions exempting them from the extensive regulations found in 42 C.F.R. ?? 482 and 483, Churchcertified institutions would have to meet a number of requirements relating to care by licensed physicians and nurses in order to qualify for federal aid under the Act.

Plaintiffs' Challenges to Medicaid Act Exemptions

Plaintiffs also challenge certain provisions of the Medicaid Act, found at 42 U.S.C. ?? 1396 et seq. The Act is designed to provide medical assistance to impoverished individuals who are aged, blind, or disabled, or are members of families with dependent children. 42 U.S.C. ? 1396. The program is jointly financed by the federal and state governments, and is administered by the states. 42 U.S.C. ? 1396a, 42 U.S.C. ? 1396b(a), 42 U.S.C. ? 1396d.

First, Plaintiffs attack the exclusion of Christian Science sanitoria from requirements imposed by state plans for medical assistance: "The provisions of paragraphs (9)(A),² (31),³ and (33)⁴ and of section 1396b(i)(4)⁵ of this title shall not apply to a Christian Science sanatorium operated, or listed and certified, by the First Church of Christ, Scientist, Boston, Massachusetts." 42 U.S.C. ? 1396a(a). Plaintiffs attack only 42 U.S.C. ? 1396a(a), and not the abovereferenced provisions.

Plaintiffs also challenge a variety of regulations promulgated under the Act which are generally designed to ensure that sanitoria qualify for payment under the Medicaid Act for appropriate services: 42 C.F.R. ? 431.610(b),⁶ 42 C.F.R. ? 440.155(b)(1),⁷ 42 C.F.R. ? 440.170(b),⁸ 42 C.F.R. ? 440.170(c),⁹ and 42 C.F.R. ? 442.12(b).¹⁰

In addition, Plaintiffs attack regulations which exclude Christian Science sanitoria from definitions of "skilled nursing facilities" (42 C.F.R. ? 456.251) and "intermediate care facilities" (42 C.F.R. ? 456.351 and 42 C.F.R. ? 456.601). Such exclusions remove sanitoria from compliance with various certification requirements for medical care, with which other institutions must comply in order to receive payment under the Medicaid Act. Defendants note, however, and Plaintiffs do not dispute, that these particular regulations have been largely superseded by changes to the "utilization review plan" requirements in both the Medicare and Medicaid Acts. Mem. in Supp. of Defs.' Mot. for Summ.J. and in Opp'n to Pls.' Mot. for Summ.J. 9 n. 9.

Finally, Plaintiffs challenge both a statutory provision, 42 U.S.C. ? 1396g(e)(1), and a regulatory provision, 42 C.F.R. ? 431.701, which exempt Christian Science sanitoria from the definition of "nursing home," allowing them to receive payments under Medicaid and Medicare without complying with state requirements for the licensing of nursing home administrators.¹¹

In sum, Plaintiffs challenge the constitutionality of fifteen provisions of the Medicare and Medicaid Acts and the accompanying regulations.

Procedural History

Plaintiffs seek: 1) a declaratory judgment adjudging the above statutory and regulatory provisions to be null and void; 2) preliminary and permanent injunctions restraining Defendants from enforcing the exemptions and paying Medicare or Medicaid funds to Church-certified sanitoria; and 3) Plaintiffs' costs of suit and attorneys' fees. Compl. at 23-24. Plaintiffs' Motion for Summary Judgment, as well as the Complaint, contend that the challenged provisions violate the Establishment Clause of the First Amendment in four respects: 1) they give aid to pervasively sectarian institutions which exist...