Hodgson v. Board of County Com'rs, Hennepin County

Decision Date08 February 1980
Docket NumberNo. 79-1665,79-1665
Citation614 F.2d 601
PartiesJane E. HODGSON, M. D.; Midwest Health Center for Women, Inc.; Paula Poe; Sandra Lackey; and all others similarly situated, Appellees, v. BOARD OF COUNTY COMMISSIONERS, COUNTY OF HENNEPIN; John E. Derus, Chairman; Jeff Spartz; Thomas E. Ticen; Richard E. Kremer; E. F. Robb, Jr.; Sam S. Sivanich; Nancy Olkon; Robert Randle, Director, Medical Assistance Program, Department of Public Health; Thomas Jolicoeur, Supervisor, Medical Advisory Unit; Edward J. Dirkswager, Jr., Commissioner, Department of Public Welfare; Department of Public Welfare of the State of Minnesota, Appellants. Carolyn COE, Individually and on behalf of all others similarly situated and Mark Tanz, M. D., Individually and on behalf of all others similarly situated, Appellees, v. Edward J. DIRKSWAGER, Jr., Individually and in his capacity as Commissioner, Minnesota Department of Public Welfare and State of Minnesota, Department of Public Welfare; Howard Kelly, Individually and in his capacity as Division Director, Hennepin County Department of Economic Assistance, Adult Medical Division, Individually and on behalf of all other Directors of County Department of Economic Assistance, Adult Medical Division for all other counties in the State of Minnesota, Appellants.
CourtU.S. Court of Appeals — Eighth Circuit

William P. Marshall, Sp. Asst. Atty. Gen., St. Paul, Minn., for appellants; Warren R. Spannaus, Atty. Gen., Richard B. Allyn, Sol. Gen., St. Paul, Minn., Thomas L. Johnson, Hennepin County Atty., and Charles F. Sweetland, Asst. County Atty., Minneapolis, Minn., on the brief.

Lynn I. Miller, Washington, D. C., for appellees; Roy Lucas, Washington, D. C., Marc G. Kurzman, Kurzman & Manahan, Maynard E. Pirsig, Gary B. Crawford, Midwest Health Center for Women, Sidney S. Feinberg, Minneapolis, Minn., on the brief.

Before ROSS and STEPHENSON, Circuit Judges, and McMANUS, * Chief Judge.

STEPHENSON, Circuit Judge.

At issue is the validity of a Minnesota welfare statute, Minn.Stat.Ann. § 256B.02, subd. 8(13) (West Supp.1978), which provides medical payment reimbursements for only those abortions necessary to prevent the pregnant woman's death or to terminate pregnancy resulting from rape or incest. 1 On plaintiffs' motion for summary judgment the district court 2 held that this restriction conflicted with the requirements of the Medicaid Act, Title XIX of the Social Security Act of 1965, 42 U.S.C. §§ 1396-1396i. The court further held that these requirements were not affected by the Hyde Amendment, Pub.L. No. 95-480, § 210, 92 Stat. 1567 (1978), an amendment to an appropriations act which forbids federal financing of abortion except where necessary to prevent death, preserve long-term physical health, or provide necessary medical procedures in cases of rape or incest. 3 We affirm the district court's ruling that Title XIX, as originally enacted, conflicts with and thus supersedes Minnesota's statutory restriction on abortion financing. We also hold, however, that the Hyde Amendment has altered Title XIX's requirements, with the result that, as a statutory matter, Minnesota need only finance those abortions contemplated by the Hyde Amendment. We therefore reverse and remand. 4

I. Background

Minnesota provides medical assistance for the financially needy. Persons meeting economic eligibility requirements may receive partial or total reimbursement for the cost of certain specified medical services. Minn.Stat.Ann. § 256B.02, subd. 8 (West Supp.1978). These services include "(a)bortion services, but only if one of the following conditions is met * * *." Id. subd. 8(13). The first condition is that, in the opinion of two physicians, "the abortion is medically necessary to prevent the death of the mother." Id. subd. 8(13)(a). The other two conditions involve pregnancy due to rape and pregnancy due to incest. Id. subd. 8(13)(b), (c). Thus, Minnesota will reimburse indigents for the expenses of life-sustaining abortions but not for the expenses of abortions that are only health-sustaining. 5

Plaintiffs in these consolidated cases 6 are patients, physicians, and medical clinics. 7 They point to several health-threatening conditions which are complicated or created by pregnancy but which are not life-threatening and which are, therefore, outside the scope of Minn.Stat.Ann. § 256B.02, subd. 8(13) (West Supp.1978). These conditions include chronic lung disease, essential hypertension, diabetes, kidney disease, heart disease, sickle cell anemia, pulmonary emboli, depression, hepatitus, fetal deformity, phlebitis, abnormal conditions diagnosed by amniocentesis, and obesity.

II. The Effect of Title XIX

Title XIX is a federal aid program that allows participating states, through the use of federal funds, to furnish medical assistance. 8 A state need not participate in the plan, but must, if it does participate, meet certain requirements. See 42 U.S.C. § 1396a(a)(1)-(40). Any state plan must provide for furnishing medical assistance to the "categorically needy." See 42 U.S.C. §§ 1396a(a)(13)(B), 1396d(a)(1)-(5). These are people who receive financial aid from certain specified federal aid programs. See 42 C.F.R. § 435.100-.135, .700-.740 (1978). A state may also choose, as Minnesota has, to provide medical assistance to the "medically needy." See 42 U.S.C. § 1396a(a)(10)(C). These are people who do not qualify for some forms of federal assistance but who nonetheless lack the resources to obtain adequate medical care. See 42 C.F.R. § 435.300-.325, .800-.845 (1978). Here too, however, the state must meet certain requirements.

First, the participating state must subsidize, for the medically needy, either the seven services it must subsidize for the categorically needy, see 42 U.S.C. § 1396d(a)(1)-(5), or at least seven of the sixteen services listed in 42 U.S.C. § 1396d(a). See 42 U.S.C. § 1396a(a)(13)(C). In satisfying this requirement, Minnesota subsidizes in-patient hospital services, physicians' services, out-patient hospital or clinic services, and "(a)ny other medical or remedial care licensed and recognized under state law." Minn.Stat.Ann. § 256B.02, subd. 8(1), (3), (4), (16) (West Supp.1978). We think it plain that these services include medical procedures to induce abortions. The provision of none of these services is subject to the condition that the recipient's life be in danger. That condition is imposed, by subd. 8(13) (with exceptions for pregnancies caused by rape or incest), only for the medical procedure of abortion.

Second, the state must "include reasonable standards * * * for determining eligibility for and the extent of medical assistance under the plan which * * * are consistent with the objectives of (Title XIX)." 42 U.S.C. § 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. §§ 1396, 1396a(a)(10)). A further objective is that policies governing eligibility be in the "best interests" of the recipient. 42 U.S.C. § 1396a(a)(19); 45 C.F.R. § 206.10(a)(11) (1978). 9

Third, the statute stipulates that the medical assistance made available to a medically needy person be "equal in amount, duration, and scope" to that made available to all other medically needy persons in his or her particular category. 42 U.S.C. § 1396a(a)(10)(C)(ii). See Roe v. Casey, 464 F.Supp. 487, 494 (E.D.Pa.1978).

Finally, regulation 42 C.F.R. § 440.230 provides that:

(b) Each service must be sufficient in amount, duration, and scope to reasonably achieve its purpose.

(c)(1) The medicaid agency may not (arbitrarily) deny or reduce the amount, duration, or scope of a required service under §§ 440.210 (for the categorically needy) and 440.220 (for the medically needy) to an otherwise eligible recipient solely because of the diagnosis, type of illness, or condition.

(2) The agency may place appropriate limits on a service based on (such criteria as) medical necessity or on utilization control procedures. 10

Plaintiffs argue that Minnesota must subsidize the medically necessary abortions of those women who otherwise qualify for medical assistance. This argument rests on two separate lines of statutory interpretation. The first is that Title XIX requires Minnesota to provide all "medically necessary" services, abortion services included. The second is that even if Minnesota need not subsidize all medically necessary services, it cannot provide services that would include abortion and other pregnancy-related services and then single out abortion services for a more restrictive standard. One or both of these lines of interpretation have been cited by judicial opinions favoring the view that Title XIX requires participating states to subsidize medically necessary abortions. See, e. g., Zbaraz v. Quern, 596 F.2d 196 (7th Cir. 1979), petition for cert. filed, 48 U.S.L.W. 3013 (U.S. July 24, 1979) (No. 79-64); Preterm, Inc. v. Dukakis, 591 F.2d 121 (1st Cir.), cert. denied, 441 U.S. 952, 99 S.Ct. 2182, 60 L.Ed.2d 1057 (1979); Doe v. Busbee, 471 F.Supp. 1326 (N.D.Ga.1979); Planned Parenthood Affiliates of Ohio v. Rhodes, 477 F.Supp. 529 (S.D.Ohio 1979); Freiman v. Walsh, No. 77-4161- CV-C (W.D.Mo. Jan. 26, 1979), aff'd sub nom. in relevant part, Reproductive Health Services v. Freeman, 614 F.2d 585 (8th Cir. 1980); Roe v. Casey, 464 F.Supp. 487 (E.D.Pa.1978); Emma G. v. Edwards, No. 77-1342 (E.D.La. Nov. 27, 1978); Smith v. Ginsberg, No. 75-0380 CH (S.D.W.Va. May 9, 1978); Right to Choose v. Byrne, 165 N.J.Super. 443, 398 A.2d 587 (1979). Apparently only one case has held to the contrary. D. R. v. Mitchell, 456 F.Supp. 609 (D.Utah 1978) (state medicaid statute...

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