Elizabeth Blackwell Health Center for Women v. Knoll

Decision Date25 July 1995
Docket NumberNo. 94-1954,94-1954
Citation61 F.3d 170
Parties, 48 Soc.Sec.Rep.Ser. 450, Medicare & Medicaid Guide P 43,994, Medicare & Medicaid Guide P 44,022 ELIZABETH BLACKWELL HEALTH CENTER FOR WOMEN; Greater Philadelphia Women's Medical Fund; CHOICE, on behalf of themselves and the Medicaid-eligible women of the Commonwealth of Pennsylvania to whom they provide financial, health care and counseling services, Appellees, v. Catherine Baker KNOLL, Treasurer of the Commonwealth of Pennsylvania, in her official capacity; Karen F. Snider, Secretary of Public Welfare of the Commonwealth of Pennsylvania, in her official capacity; Sherry Knowlton, Deputy Secretary of the Office of Medical Assistance of the Commonwealth of Pennsylvania, in her official capacity; Robert P. Casey, Governor of the Commonwealth of Pennsylvania, in his official capacity, and their successors. Catherine Baker Knoll, Karen F. Snider, Sherry Knowlton and Robert P. Casey, Appellants.
CourtU.S. Court of Appeals — Third Circuit

Sandra W. Stoner (argued), Office of Atty. Gen. of Pa., Harrisburg, PA, for appellants Catherine Baker Knoll, Karen F. Snider, Sherry Knowlton, Robert P. Casey.

Mary A. McLaughlin (argued), Dechert, Price & Rhoads, Philadelphia, PA, for appellees Elizabeth Blackwell Health Center for Women, Greater Philadelphia Women's Medical Fund, CHOICE, on behalf of themselves and the Medicaid-eligible women of Com. of Pa. to whom they provide financial, health care and counseling services.

Frank W. Hunter, Asst. Atty. Gen., Michael R. Stiles, U.S. Atty., Barbara C. Biddle, Alfred Mollin, Attys., Appellate Staff, Civ. Div., Washington, DC, for U.S. as amicus curiae.

Before: COWEN, NYGAARD and ALITO, Circuit Judges.


COWEN, Circuit Judge.

The Elizabeth Blackwell Health Center for Women, a comprehensive reproductive health care facility that provides first-trimester abortions, the Greater Women's Medical Fund, a non-profit agency that provides financial assistance to low-income women in order to obtain abortions, and CHOICE, a telephone hot-line which provides information and referrals to its callers on many issues, including family planning and abortion (collectively, the "Providers"), ask this Court to declare invalid and enjoin the enforcement of sections 3215(c) and 3215(j) of the Pennsylvania Abortion Control Act, 18 Pa. Cons.Stat.Ann. Secs. 3201-3220 (1983 & Supp.1994), Pennsylvania's reporting and physician certification requirements for publicly-funded abortions under the Medicaid program. The Governor of Pennsylvania, the State Treasurer, the Secretary of the Pennsylvania Department of Public Welfare, and the Deputy Secretary for Medical Assistance (collectively, "the Commonwealth") appeal from the order of the district court granting the Providers' motion for summary judgment. The district court based its holding on the Providers' claim that the Pennsylvania statute is preempted by the Hyde Amendment.

We conclude that the Secretary of Health and Human Services is owed deference regarding her interpretation of the Hyde Amendment mandates. Because the Secretary has determined that reporting requirements are permissible under the Medicaid Act, as modified by the Hyde Amendment, only if they contain a waiver provision, and since the Pennsylvania Abortion Control Act contains no such provision, we find Sec. 3215(j) of the Pennsylvania statute directly in conflict with federal law, and thus, invalid to the extent that it conflicts with the Secretary's interpretation. Furthermore, because the second-physician certification requirement pursuant to Sec. 3215(c) is contrary to a federal regulation, it is also invalid to the extent that it goes beyond the scope of that regulation.


This action concerns Title XIX of the Social Security Act, commonly known as the Medicaid program, 42 U.S.C. Secs. 1396-1396u (1988 & Supp. V 1993). The purpose of the Medicaid program is to help provide medical treatment for low-income people. Under the program, the state receives federal financial assistance in return for administering a Medicaid program that the state develops within parameters established by federal law and regulations. 42 C.F.R. Sec. 430.0 (1994).

Establishment of a Medicaid program is voluntary on the part of each state. While states are not obligated to participate in the Medicaid program, each state that chooses to do so is required to develop its own state plan which must be approved by the Secretary. In order to receive federal funds, a state's plan must conform, both on its face and as applied, with various federal requirements. 42 U.S.C. Sec. 1396a, 1396c; see Harris v. McRae, 448 U.S. 297, 301, 100 S.Ct. 2671, 2680, 65 L.Ed.2d 784 (1980); New Jersey v. Department of Health and Human Services, 670 F.2d 1284, 1286 (3d Cir.), cert. denied, 459 U.S. 824, 103 S.Ct. 56, 74 L.Ed.2d 60 (1982).

Under Title XIX, certain categories of medical care are mandatory, and must be provided by every state Medicaid plan, while other categories of care are optional, and each state has the discretion to cover the service. See 42 U.S.C. Sec. 1396a(a)(10). By law, states are required to fund medically necessary physician services. 42 U.S.C. Secs. 1396a(a)(10)(A), 1396d(a). Participating states must establish eligibility requirements that are "consistent with the objectives" of Title XIX. 42 U.S.C. Sec. 1396a(a)(17). "Title XIX's broadly stated primary objective [is] to enable each State, as far as practicable, to furnish medical assistance to individuals whose income and resources are insufficient to meet the costs of necessary medical services." Beal v. Doe, 432 U.S. 438, 444, 97 S.Ct. 2366, 2371, 53 L.Ed.2d 464 (1977) (citing 42 U.S.C. Secs. 1396, 1396a(a)(10)). "A further objective is that policies governing eligibility be in the 'best interests' of the recipient." Hodgson v. Board of County Commissioners, County of Hennepin, 614 F.2d 601, 607 (8th Cir.1980) (citing 42 U.S.C. Sec. 1396a(a)(19); 45 C.F.R. Sec. 206.10(a)(11)). The state must also provide safeguards to assure that its Medicaid plan will be administered "in a manner consistent with simplicity of administration." 42 U.S.C. Sec. 1396a(a)(19). On the other hand, the state must "provide such methods and procedures relating to the utilization of, and the payment for, care and services available under the plan ... as may be necessary to safeguard against unnecessary utilization." 42 U.S.C. Sec. 1396a(a)(30)(A).

In addition, federal regulations require that each covered service be "sufficient in amount, duration, and scope to reasonably achieve its purpose," 42 C.F.R. Sec. 440.230(b) (1994), and mandate that states "may not arbitrarily deny or reduce the amount, duration, or scope of a required service ... to an otherwise eligible recipient solely because of the diagnosis, type of illness, or condition." 42 C.F.R. Sec. 440.230(c).

If, after a hearing, the Secretary finds that an approved state plan no longer complies with the provisions of the Medicaid Act, or that the state had failed to comply substantially with any applicable federal requirement, the Secretary may notify the state that federal financial participation will be withheld or limited. 42 U.S.C. Sec. 1396c.

In 1976, Congress passed what is commonly called the Hyde Amendment, which prohibits federal reimbursement for abortions except in the narrow circumstances that Congress deems to be medically necessary. Since 1976, Congress has added the Hyde Amendment to annual appropriations bills for the U.S. Department of Health and Human Services ("HHS"). While its provisions have varied to some degree from year to year, the effect of the Hyde Amendment has been to withdraw federal funding under Medicaid for most abortions. 1

The Hyde Amendment for fiscal year 1994 permitted, for the first time since 1981, expenditure of federal funds for abortions when "the pregnancy is the result of an act of rape or incest" as well as when "necessary to save the life of the mother." Pub.L. No. 103-112, Sec. 509, 107 Stat. 1082, 1113 (1993). The full version of the 1994 Hyde Amendment provides:

None of the funds appropriated under this Act shall be expended for any abortion except when it is made known to the Federal entity or official to which funds are appropriated under this Act that such procedure is necessary to save the life of the mother or that the pregnancy is the result of an act of rape or incest.

Id. 2

This Court has previously held that the Medicaid statute, as modified by the Hyde Amendment, requires participating states to fund those abortions for which federal reimbursement is available. Roe v. Casey, 623 F.2d 829, 836-37 (3d Cir.1980). See also Hodgson, 614 F.2d at 605; Preterm, Inc. v. Dukakis, 591 F.2d 121, 134 (1st Cir.), cert. denied, 441 U.S. 952, 99 S.Ct. 2182, 60 L.Ed.2d 1057 (1979). We are bound by that precedent here. Accordingly, under Medicaid, funding for rape and incest abortions is mandatory for participating states.

The 1994 Hyde Amendment was reported out of committee with a provision requiring women seeking reimbursement for rape and incest abortions to report the crimes to the appropriate law enforcement officials. 139 Cong.Rec. H4304 (daily ed. June 30, 1993) (Sec. 207). However, a point of order was raised that the Hyde Amendment language violated parliamentary procedure of the House of Representatives, which prohibits attempts to "legislate" on an appropriations bill. The point of order was conceded and the entire amendment stricken from the bill. 139 Cong.Rec. H4307-08.

The Secretary of HHS has delegated her authority to oversee and enforce the Medicaid program to the Health Care Financing Administration ("HCFA"). 49 Fed.Reg. 35,247, 35,249 (1984). HCFA has promulgated a regulation that provides:

[Federal funding] is available in expenditures for...

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